Teaching Moments, Learning Moments

19 October 2016

The last session after 6 weeks with the first group of 22 4th year medical students was Friday morning. It was post-exam feedback for them and for us. Of course, they find it difficult to critique us, even anonymously. All our lectures were given a 9 or 10 out of a possible 10. Yet when I asked them, “Don’t you find lectures boring?”, there was a universal groan of acknowledgment. I figure only two asleep out of 22 by the end of a lecture is pretty good. Then I brought up a case presented to me in clinic which, for reasons not fully transparent to me, I misdiagnosed. A 75yo man, who’d worked his whole life in the S. African mines, with 8 months of progressive dementia had, I learned later, difficulty walking for two months and urinary incontinence for 2 weeks. The triad, when presented that way, suggests Normal Pressure Hydrocephalus, a condition whereby the exit for the flow of cerebrospinal fluid in the ventricles is blocked. The fluid-filled ventricles enlarge and other parts of the brain are under pressure to shrink.  His wife described that his older sister died 4 months ago with dementia. It was a red-herring but I bit, thinking of Alzheimers.  His wife and son flanked him, she with her arm lain over his shoulders the entire time. It was very touching and I excoriated myself when I realized I’d missed the (probable and possibly reversible) cause of his infirmity.  Well, I announced to the students that I missed the diagnosis and would follow-up with the man to get a CT scan. Whether he can be shunted (from the ventricle to the abdominal cavity) is another question in this country without an adult neurosurgeon. Anyway, the teaching points were two: 1) we can all make mistakes and learn from them and 2) the students should not be afraid to challenge a physician higher on the totem pole, courteously, because they may have an insight or information their “superior” doesn’t have. I’ll likely not know if this will alter their behavior but I had to try. I’ve ordered the CT scan.

I have to reverse engineer my granola here. That is, I cannot make my own since there are no oats to be had, despite Malawi having been “discovered” by the Scots (“Dr. Livingston, I presume” in the 1850’s.) and a British colony for years. So I buy granola, which I like occasionally for breakfast with yoghurt, bananas, and milk, and have to soak it a couple of times to get the sugar out of it. Then I dry it in the oven on low. Then repack it for use later.

I find I am most drawn to writing about the patients I see, which probably isn’t of enduring interest to much of my audience. The rest seems external and ephemeral or insubstantial, whereas individual suffering is so palpable and genuine. And I am quite critical of docs, psychiatrists especially, who write and publish about their patients—Irv Yalom, Robert Lindner. Even Oliver Sacks. As they make a living doing it, I fear it is exploitative. Often the tales are so unique I cannot imagine that the individuals aren’t identifiable. I sympathize with the urge however and think that the patients I describe herein are much more anonymous. They are often from tiny villages in rural Africa without electricity or books—and this isn’t a book—where most of the people who know them are not literate. Perhaps I’m just rationalizing.

I saw a College of Medicine student yesterday, an advanced one who has been doing well in school. After taking one of three exams required at this time, and he felt well prepared for them, he got in a car with a stranger who took him to a market where he was confused and disoriented and ran, thinking others thought he was “mad”. The police eventually brought him to Room 6 where he was seen. My diagnosis, after talking with him, is that he dissociated and had an actual fugue state experience. You know, you find yourself on the train to Philly and have no idea how or why you are there? He is eager to go right back and finish his exams and confessed that he had been feeling a lot of pressure from home. His parents and younger siblings live in a village and are very poor; his father recently told him, “You are our only hope.” Seems like a lot for a student to carry. When he said this, he looked about to cry and I, automatically, began to tear up in sympathy. I trust that in myself and do not think he was trying to shuck and jive his way out of the exams. And if he was, it ends up harming no one. I know numerous professors of psychiatry in the US who are much more dishonest and destructive of others—fudging drug research for their own (pecuniary) gain—than he. Not that they shouldn’t lose their licenses, which they should.

We went to Liwonde National Park for three nights over the long weekend. Saturday was Malawi Mothers’ Day. I took a minibus for 2 + hours, starting with 15 and ending with 21 passengers. Linda came from Lilongwe where she was helping to administer practical examinations for students from the Kamuzu College of Nursing. We met on a dusty stoop in Liwonde and awaited a driver from Liwonde Safari Camp, where we stayed. We slept in a—get this—two room tent on a platform elevated up in the trees. The birdsong starting about 4AM was insane, like a kindergarten class with all those funky instruments, everyone playing from a different piece of music. Of course, during the night the snapping of branches and flashing of lights alerted us that the elephants were in camp and the staff were trying to move them out.

We took a 3 hour boat ride on the Shire (think, “Shirry”) River, which drains Lake Malawi and feeds the only hydroelectric plant in the country. Liwonde National Park is 538 sq km, and is filled with animals and birds. The river has more than 1000 hippos and as many crocodiles. A significant number of men fishing from small dugout canoes are eaten each year. We saw huge fish eagles galore, goliath storks, pied and malachite kingfishers, sacred storks, white-crowned spotted weaver birds, and on and on. A herd of elephants was tromping through the muck at the shoreline, munching grass. A huge one lay down and our guide said, “That is amazing. You never get a picture of an elephant lying down.” I did. And found out the next day that it was dying—and died. We saw a little Babar suckling from his mom. It was only equaled by the driving safari—in an ancient diesel Land Rover with a sun canopy—the next day, where we saw herds of impala (quicker and much lovelier than the eponymous Chevvy), sable antelope, wart hogs with their quick little trot, kudu, bushbuck, waterbuck, and massive termite mounds. And baobab trees everywhere, often girdled by the elephants feeding. The trees don’t have a cambium layer, the water being transported up the tree throughout the trunk, so they don’t perish when girdled, like most trees. All I know about this I learned from the very astute and well-informed guides. It was a relaxing and wonderfully pleasant 4 days. The minibus trip home with Linda set a record—-25 people most of the way. There were 8 people in the seat in front of me, tucked in and tangled up. The inevitable police stops, presumably to see if the minibuses were carrying more passengers than was safe, were easily negotiated as the spotter/assistant to the driver coolly slipped the investigating officer some Kwatcha. Always be polite and deferential, unless you want to be dragged off to jail. The arbitrary abuse of power by police, everywhere, is infuriating and I’m not even a person of color!

So it’s back to “home”. Our frangipani tree has a flower so we know it will be a coral flame in our front yard. Mangos are coming in. Linda likes them tart and on the early side. I prefer the ripe, sweet, soft ones which will come later.

I went to clinic this morning for our Wednesday AM meeting, which I initiated at my boss’ suggestion. Dumb me. I presented a case for discussion the first week and it was fun and lively. No one else has come forward to present a case. In fact, when I arrived at 9 this morning, they had a young, depressed nursing student for me to see. So the conference is moribund and I should know better. I’ll revisit it with the staff, seeing if they have a desire to meet and discuss clinic issues like patient flow and charts, problematic or interesting patients, or topics we frequently encounter, like dementia. And if they do have such an interest, when would they like to do it? Not including them from the start was not my brightest move; I just assumed everyone would like to do it as much as I would. Which they might, if they have a hand in the planning.

Another teaching/learning moment. Life seems filled with them.

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