[Above photo: A map on Robbin Island of the West African slave trade. Malawi’s slave trade was generally from East Africa, Mozambique.]
3 December 2017
Time is a strange concept. Or at least we think of it strangely. It’s like driving in a car. You are in the car, sitting comfortably in a contoured seat, belted in hopefully, then you get out of the car in a different time and place, having just sat there. Nothing is rushing by, nor are we rushing through it. We struggle to live in the moment, we overworked Americans, always thinking about the next paving stone on which we’ll step, but never realizing it because as our foot hits it we are already thinking ahead to the next. I’m getting out of my depth here—I’ll leave it to Einstein and Stephen Hawking to finish this paragraph. Let me just note how pleasantly jarring it was to receive an email from Harold, traveling on the BART to Berkeley from San Francisco with his sister Ellen, having had supper with Stephen Arkin at an Indian restaurant in the City. All our lives have been intertwined in various ways since 1962 and Harold and Ellen are hurtling down the tracks underneath the Bay, Stephen has likely walked to his home on 5th Avenue, and I am sitting on a couch in our cottage in Blantyre, Malawi and we are practically talking. And, no, I have not been smoking the local herb. I’m sitting up in bed and it is 6:44AM Sunday.
I really hit the wall this week. I worked much too hard, too many hours—-and I mean starting at 7:30 or 8 AM and working straight through until 5 or 5:30, no lunch, rushing from QECH on my bike to COM and, later, back again. I bowed out of an evening meeting, exhausted. Curiously, I don’t think I would have felt much less exhausted 30 or 40 years ago. My recovery time would have been shorter, though.
In part it had to do with a 31 yo woman I saw in Room 6 with the medical students. She was there with her mother. She is a primary school teacher in a rural district, Chikwawa. She had delivered a baby three months previously and had been acting strangely since returning home from the hospital. She had no interest in the baby, refused to nurse it, and began talking to herself and refusing to eat. Her mother, sadly, didn’t bring her to the local clinic, perhaps feeling with hopeless resignation that this was just yet another disaster in a life filled with them. In any case, 5 days before coming to see us she killed her baby. I’ll not put the images of how she did this in your head, despite my vicariously traumatized Self feeling a pressure to do so, to futilely attempt to get it out of my mind. When we saw her she was mute, had made no efforts to harm herself, was staring fearfully, uncomprehending, and was flagrantly psychotic. We treat many acutely psychotic patients as outpatients with frequent follow-up. I can only think I was so horrified by it all that a bit of my judgment left me. I was aware that she would likely be at very high risk of suicide when she improved and could form coherent thoughts. Anyway, I talked about it with Linda that evening and she was surprised I hadn’t hospitalized her. And hadn’t called the police. I slept poorly, my best guide to whether a potentially suicidal patient should be in hospital, and returned to Room 6 the next day to retrieve the mother’s phone number. I called her twice, saying that she needed to bring her daughter in to be hospitalized at Zomba Mental Hospital. She refused: “She’s getting better.” I upped the ante, saying her daughter had killed the baby and unless she brought her in I’d be forced to send the police for her. And that would be much more unpleasant for her daughter. No dice. I asked one of the nurses to call her and do it all over again in Chichewa. Nope. I was about to call the police when I gave her a last try and this time she agreed to bring her daughter in. And did, as was confirmed in the early afternoon. I am assuming she was hospitalized, as I was teaching and couldn’t f/u with the nurses, but they know what to do.
I don’t know how I made that lapse. Thankfully no major harm was done. I’ll call the police and report it on Monday. They’ll likely be grateful for not having to book her, etc. I was stunned by the horror of it. I also was pressed for time, as we are short-handed teaching the students and I needed to give a lecture at the COM shortly. In describing this to the students later, I pointed out how we all will make mistakes, despite our best intentions, and the second most important thing is to face them and talk about them and learn from them. My fear that in doing so I’ll be unmasked as really incompetent—“You didn’t hospitalize her? What were you thinking, idiot?!”—was easily outweighed by my need to demonstrate the above conviction.
In Medicine, our best diagnosis (management plan, etc.) is only as good as our last one. Brilliance or compassion on Monday is erased in an instant by thick-headedness or insensitivity on Tuesday. If a significant part of your self-esteem is pinned to your job performance and you lean toward guilt and self-blame, it leaves you pretty vulnerable, since there is information we cannot know, variables we cannot control, states of our own mind (rushed, horrified) of which we may be unaware and which modify our senses and judgment. Being a physician is a risky business, if taken seriously, because the stakes are so high—potentially harming, or failing to protect or properly help, another person who has, somehow, become your responsibility. It’s not like you double-faulted at tennis several times and lost the match or missed the mark in creating an advertisement that flopped (We are watching “Madmen”) . Often, then, the primary loser is you—and a business, perhaps—not someone else who has entrusted themself to your care.
I am excited to have started in motion a possible assist for the sustainability of the Pediatric Mental Health Clinic. I’ve asked two training directors at university medical centers to consider a 3 month rotation of senior Child Psychiatry fellows here. Global Mental Health is the Next Big Thing, given the predicted health burden of mental illness in developing countries (conservatively 15-20% of the illness burden). I’ll cast my net more widely in future days.
Doing Medicine in a developing country where resources are short, skills are sometimes poor, health care workers are stretched too thin, patients are desperately ill, and there is little system redundancy to catch errors of omission or commission, is hard. Crazily, I like the challenge, even as it exhausts me at times. And I like to see people getting better in association with our efforts.
A 28yo man from a small village with three prior hospitalizations for mania was in clinic Thursday for a review. He takes medication for his Bipolar Affective Disorder without having any side effects and it is well-controlled. He was dressed in a pressed, dark suit for our visit, accompanied by his mother as Guardian. He is a successful potter, hand-building and firing small to large pots, which he sells. I asked if he had a wheel and he looked puzzled! He supports his wife and 2 children and his parents with his work. He looked very proud as he talked about it. I sense he lives in the moment, his moment and that of others around him. It buoyed me up, I must say. He’s a lucky one.