My first week at the clinic

It is about 5:30 here and it's dropped from somewhere in the 90's to a breezy 83. From the porch I can see clouds piling up on the mountains of Burma about 2km away. The wind is shifting this way and will blow them on top of us for about 45 minutes of torrential rain. A housemate Daniel says we have about 30 minutes. The weather here is fairly predictable. During the rainy season it will rain all the time. Now towards the end, you just know not to plan anything or be out of doors between 5 and 7.

My first week at the clinic was good. I was in the reproductive health outpatient clinic, doing mostly routine prenatal screening and exams. It's not unlike the US -- similar testing (HIV, VDRL, blood typing, but not GBS), similar exam, similar vaccinations (except people in the US usually already have them). It's worth noting that I had one patient all week over 110 lbs and the only blood pressure I saw above normal was a systolic of 130.

Being a student is not unlike at home. You see patients and know what to do for many of them. If you don't, you ask someone else -- there aren't any doctors in the RH outpatient clinic, but some of the medics have been doing this for ten years or more. If the person you ask doesn't know, you figure out the safest of what you think are possibilities and tell them to come back soon if they don't feel better, then you go home and look it up.

The process of becoming a doctor is about learning lots of things. There are big conceptual things, but also a thousand discrete little things. For instance, what's the best way to clean out an ear that is completely packed with wax? When I saw a patient with that problem I didn't know. We sent her home with an antibiotic for the infection she was incubating back there, tylenol for the pain, and instructions to do frequent saline soaks/rinses. I now know that I could have done a 30 minute soak, fashioned a pressure-washer out of a syringe and IV cannula, and used that and a toothpick to gently clean things out. One advantage of being here for a year is that I'll see an extra thousand or so patients and learn all this trivia so that when I'm an intern and presented with similar situations I'll be able to act with confidence.

This is a rather cynical comment but often seems true: the funny thing about academic medicine is that sometimes the attending doesn't really know what to do or doesn't have evidence to back up what he/she prefers, but the student/intern is always wrong. If I were doing the above irrigation and the attending asked what I was doing, a reply of, "I don't know, it just made sense," would lead to a brow-beating. If I said "according to the Journal of American Family Physicians this is the best thing to do," I might get a response (especially from an internist or pediatrician) like "never listen to what family doctors say," but it would not reflect poorly on my competency, although I could expect some 'good natured' harassment about reading how family medicine doctors do things. Another advantage of coming here for a while is not having to endure this scenario every day.

Anyway, life outside the clinic is also good. I'm starting to see what my time here might look like. I have something like 6-10 months. I can see spending a week in each of the outpatient clinics, a month in each of the four inpatient wards, and six weeks (maybe more?) working with a local (though renowned) malaria research group. That gets me well into the 6-8 week range without repetition, and then I can either go home or repeat things.

Today I went to a meeting of the group I worked with two years ago. They are doing well, and it was good to see familiar faces. As their situation has changed it seems like the group has reorganized and re-focused well. I've volunteered to help the new technical adviser with grant writing so I can still be involved and learn a little bit about the funding of these sorts of ventures.

I think the only other big news is that I have a new bike. I didn't want to, but a shady bike chop-shop had far and away the best bikes and deals. The word around town is that it's where the police sell all the bikes they 'confiscate' and turn an unofficial personal profit. However, all 5 gears work, the bottom bracket is tight and recently greased, it rides quietly. None of the above were available at the price from the other used bike shops (which were lean-to's in the Muslim district).

As a last bit of trivia, I have read that the Muslim folks followed the trade as land routes to this area opened up. Historically they have been traders and made up a merchant class in between the indigenous people and the colonizers. Things aren't as regimented as they once were, but evidence remains. I've found they are the most pleasant people to do business with. In Thailand there are many people trying to rip off foreigners. I have never gotten that impression in the Muslim area. It's more like they really want me to be happy with what I get and will repair it when it falls apart in a few days. The bargaining process is just something you do. I often feel like it's end-point is obvious from the beginning, and more persistence from either party might change it by a few percent, but I don't feel like they are genuinely trying to persuade me to spend $50 on fake gems or similar. However, I did buy from the corrupt cops.