Imperfect Medicine

I need to step back. I need a recharge. I need to shake out of a pattern of negative thinking and emotional reaction. So I write.

My busy clinic schedule running all over the city and countryside usually leaves me feeling energized and useful. But lately all complaints sound the same, and I'm left feeling frustrated trying to differentiate one person’s malnutrition from another persons depression from another person’s fabrication in order to get some colorful free pills.

It is easy to start feeling exhausted by the complaints, the reports, the misery and my helplessness to interceed. As I look at one patient after another wondering what an intervention I might offer will do to change their plight, I have to work to keep from sinking.

The medicine I practice is in no way sophisticated. Sometimes I entertain myself with running a list of possible diagnoses through my head as I examine my patient, listing off the tests I would order if in the States, the specialists I’d consult, the care I’d prescribe. Some days I’ll write out such recommendations because the patient deserves to know what they need; yet I know full well I’m essentially just wasting a piece of paper.

The reality of Haiti is harsh. I knew this coming in, I've known it and learned it each day I"ve been here. In comparison to other areas of Haiti, I'm seeing people who are the best nourished with the most opportunities. In the remote areas of this country, people sit in their homes or on the side of the road and starve slowly in the heat.

There are no shortage of medical clinics in Port-au-Prince. I pass about 5 on my commute to work. The Haitian doctors here hang their shingle and ask for a little money for consultation, pharmaceuticals and lab work. They can't work, live, survive without it. But a little money tends to be prohibitive to most patients.

Volunteer medical teams are a frequent occurance in Haiti, so much so that my white face can sometimes draw a crowd by itself. Surely there is something free waiting to be handed out. The longer I'm here, the more I start becoming associated with CONASPEH and an organized program of outreach, the numbers have started to dwindle. Because really, what can I do to change chronic and systemic problems that cause so much of the disease and suffering? I think the patients I see know more than they let on. As they list their complaints, I'm sure they know that if they had regular food and clean water, maybe their stomach wouldn't hurt all the time. Maybe they get tired of recommendations of labs, of drugs to buy, of specialists to see that they can't afford to follow through on. Maybe they don't want to worry about that mass in their stomach that they don't have the money to have a surgeon remove... its easier not to know it might be cancer. And they look to me to hand them something in my little pharmacy that will give them strength, take away pain, and likely erase years of suffering settled into their bones.

I remember in residency having moments of nearly resenting some of my chronic pain patients. I was not alone in that sentiment and such feelings were talked about often in processing sessions the residency coordinated. Why would a group of doctors dedicating their life to “helping” people feel frustration and resentment toward people asking for help? Usually it was because we felt manipulated for drugs, got tired of having to be an investigator—sniffing out real pain from addictive drug seeking behavior. But I think ultimately the fact that we didn’t have an easy fix to our patient’s suffering, whether it be from chronic pain or addiction and depression, was what left us all frustrated. And as a defense mechanism, we sometimes turned our frustrations on our patients out of fatigue and feelings of helplessness. Residency helped us recognize those defensive reactions and deal with them before walking into a patient encounter. I'm finding that I'm pulling out such self-evaluating tactics even here in Haiti.

Yesterday I saw a 96-year-old woman, which is a feat in and of itself in a place where the average life span is 52 years. She sat and told me, “my whole body hurts, my head feels empty, my stomach crawls up, I can’t sleep, my bones are hot, I can’t eat, my mouth doesn’t have good taste.” Her list of complaints was almost exactly what her daughter had reported and the patient before her and before her….

I gave her a thorough physical exam, commended her on her sinewy strength, and then opted to do no harm and gave her a couple of little sacks of vitamins, Tylenol for joint pain, and Tums for reflux.

But her daughter had gotten cough medicine, and she really wanted that.

In fact, she kept asking for more medicines. She laughed when I tried to explain why I wasn’t just dumping the pharmacy into her outstretched hands, but she was not to be appeased. Miss Fano smiled and gave her a couple of Halls Cough Drops. They have enough vapors in them that they resemble pretty strong, magical medicines, and that seemed to make my ancient patient happy although clearly disappointed in the blan doctor.

With this elderly woman, we were able to laugh. Of course she was suffering, and in all reality at the end of her life. There wasn’t much I could (or should) do to change that fact. But similar situations happen with patients of all ages. Regardless of my best teaching, my most protective use of pharmaceuticals, sometimes it comes down to how colorful the medicine are and how many a patient will get which determines how good of work I do in the eyes of my patients. I’m left unsatisfied knowing what diagnostics they would benefit from, what intervention, what lifestyle changes, what tertiary care could truley change their health situation. My patients are left unsatisfied when the pills I hand over don’t have the magic to erase the misery.

One patient who had diarrhea several months back keeps asking me for more of that “force” powder (Gatoraid) that I had given her when she had diarrhea and fatigue. I have since ran out, and tried to give her a recipe for a homemade concoction, but she was disappointed that the sugar/salt water rehydration mix isn’t a magical blue color, and is sure it is not as strong.

So I find myself from time to time frustrated, just short of loosing patience with patients who don’t and can’t understand the pharmacology behind the colorful pills, angered at a pervasive system that allows such inefficiencies and negligence of care, frustrated to at best be offering a little bandaid treatment for anemia and gastritis when the true healing medicines would be clean water, food, jobs, income, mosquito eradication, environmental rehabilitation and education.

So this morning I march off to another clinic. I am trying to meditate on the morning, on the service of being present, finding perspective in the very imperfect work I am doing.