Coasting (in high gear)

4 February 2018
[Above photo: Fishermen heading home, Domwe Island as the backdrop.]
I am getting more efficient and focused in my work. I have created a sort of “formula” for lecturing. I begin with a topic, learning objectives, eliciting from the students their thoughts about the signs and symptoms, differential diagnosis, management, epidemiology, etc. related to the issue at hand, present the bulk of material, and end with 5 or so clinical scenarios we use to discuss what we have learned. It is all very simple and interactive and the students stay engaged.
I’ll apply for a grant to run 3 workshops. One will be for the Room 6 psychiatric nurses and our psychiatric registrars and newly minted psychiatrists to help them develop child and adolescent psychiatry skills. It will be two afternoons, covering child and adolescent development, assessment, diagnosis, and management. Perhaps I’ll include Pediatric registrars in the mix. Then we’ll do a larger one for the psychiatric nurses and clinical officers from the 13 Blantyre District clinics to teach them adult psychiatry. Finally, I’ll teach a reprise of the first workshop for the latter audience. I should be able to manage that easily, in addition to my other workload, before I leave. My concern is that I leave child mental health services here in substantially better shape than I found them (non-existent). It is nice to build something but not of much value if it disappears after you are gone.
I saw a 19yo woman in clinic for the second time three days ago with the medical students. She had been not sleeping, was very talkative, demanding, grandiose, and otherwise appearing hypomanic when I saw her with her aunt and mother two weeks earlier. Her mother has a history of 3 episodes of puerperal psychosis and there are two cousins with mental illness. I thought I had found a mood disorder cluster in her family. The young woman was now feeling normal and sleeping well with the very low dose of medication I had given here; she didn’t progress to full-blown mania. It turns out that the mother also wanted to be seen on this visit. So I had the medical students gather a full history on her. The patient was her last-born and she hadn’t been to hospital since but has been taking medications, antipsychotics, continuously for 19 years. She continues to hear “voices” coming from a “radio”—and there is no radio in the vicinity—telling her to go to the market and beg. They don’t really disturb her, other than making her feel a bit “captive” to them. Otherwise, she socializes well, takes care of her house, eats/sleeps well and has no other complaints. It is curious. We know that puerperal psychosis is much more common in families, and individuals, with a history of mood disorder. In addition, stress can exacerbate schizophrenia so giving birth might do that. Yet she appears too engaging, too intact to really have schizophrenia. Is she even psychotic? It points, more than anything, to the trouble we have with diagnostic nomenclature and, more fundamentally, knowing what in heck is going on in people’s brains.
Speaking of focus, at the ripe old age of 77yo I am getting evaluated for ADHD. I am scattered and always have been. I struggle to listen to conversations if there is more than one going on in a room. I have always had difficulty with beginning projects that I lose interest in before I finish, moving on to the next. In 2nd grade, I was the only child who had to copy a page of a book (I chose a famous abridged version of Shakespeare—why was that?!) every night in an attempt to improve my penmanship (didn’t work). I always have a stack of half-read books by my bedside. And I can be incredibly impulsive. I’ve felt like my daughter’s dog, Oscar, when you say, “Squirrel.” He’d lose all sense of what he was doing, as well as his sense of safety, and immediately try to locate the squirrel. No matter that it was on a telephone wire across a busy street—he would tear off after it. On the other hand, I’ve done well in school, made and kept good friends, and been able to focus well with patients. But, with Linda’s urging, I am getting evaluated and going to give methylphenidate (Ritalin) a try to see if it makes my life easier. My major reluctance, beside not wanting to take or be dependent on medications, is that if it really works, I’ll kick myself for not trying it sooner! Oh, well. Life’s a process.
I feel so much better, overall, when I jog. So I have started jogging to the track at the COM Sports Complex, making 4 circuits, and jogging home. I am ashamed to say my time is 12 minutes per mile! I’m sure that will improve as I do it some more. I haven’t run seriously or regularly since before my lung cancer 10 years ago this April, so I have some training to do.
I finally managed to reach the US Embassy in Myanmar and had an interview with two pleasant women. They seemed very positive about my application. They’ll provide quarters in a “Guest House”. (I may pay for my own quarters elsewhere.) I’ll be training graduated psychiatrists, teaching both Adult and Child/Adolescent Psychiatry, and working with others who want to open an inpatient facility for adolescents. I also may train mental health nurses. My interviewers asked if I would be willing to travel between Mandalay and Yangon and teach at both medical schools. A plane flight is less than 45 minutes air time and I like both cities. I would be willing to, although presumably for periods of time, not alternating days or weeks. There are a few hoops through which to jump, primarily arrangements and contracts to be made with each institution, but it sounds as if I may be in Myanmar in January 2019. It is very exciting for me; I’ve wanted to return to SE Asia since I was first there in 2004, teaching with a group in Vietnam. It takes me further from settling into Maine, as I would like to do, and will put some distance between Linda and myself. She wants to be near her grandchildren and has her own fish to fry in the US, not to mention the very possible Midwifery Ward she is trying to get up and running here at Queens. So she may be in Malawi some, in Myanmar some, and in Bar Harbor-Boston some. I worry about feeling too lonely or deprived but I know I am a good sublimator and can derive a lot of pleasure creating something useful wherever I am. The final word isn’t in but I am optimistic.
I was accepted for a poster presentation, but not for a talk, at the NCD conference at Makerere University in Uganda. It is understandable I wasn’t asked to speak because my talk would be about developing capacity for child and adolescent mental health services here, not research. But it isn’t worth the time and $ to me to go and do a poster session, especially since, in fairly typical fashion for meetings in this part of the world, I was notified of my acceptance 12 days before the conference. I am seeing if one of our GHSPers in Kampala is going to the conference and can print and put up a poster I electronically send to them. If not, so be it. I have submitted an abstract of a talk as part of a panel on the same topic for the American Academy of Child and Adolescent Psychiatry annual meeting in Seattle next October. It would have been fun to do it in Kampala, though. And to see the mountain gorillas in Ruanda.
This is very uncontrived and simply flows from my brain through my fingers today. I have no idea if it is of interest or well-conceived/written. When I feel that way, I remind myself that my blog was started as a diary so I’d have a written record of my time here. That relieves pressure I might feel to craft it more carefully.

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