The True Thursday Events

Ok, so I started a whopping one sentence of Thursday's actual events and then fell asleep. So just pretend it's still Thursday. Also, I've heard that a few people have tried to post comments and were unable to do so. Good news! I changed the settings and you can feel free to comment, question, or critique as you like. Please let me know what you think and what you're wondering.

So much happened at Icyuzuzo today that I may have to split this all up! I'll keep it brief, I promise...hahaha. I spent the day following Dr. JMV. Nina and I sat in his office and saw patients with him. Phenomenal experience! A car drove us to the clinic and we went immediately into Dr. JMV's office to wait for him. On the way to the WE-ACTx clinic in Santra-Ville, my shoes were bugging me and I ended up with a bunch of blisters on my feet. I asked for band-aids at both clinics and was informed that neither clinic had any. Let me repeat that, no band-aids. Ok, again for those of you struggling to fit your head around that one (much like my initial reaction, so you're not alone!) NO BAND-AIDS. A clinic that performs routine blood draws on HIV+ patients and sees people who end up with skin lesions...doesn't...have...band-aids...Insane? Yes. Shocking? Not so much. These clinics are lucky to be staffed with physicians and have supplies of ARVs so band-aids aren't really a priority. Close your eyes and imagine being that poor.

Nina and I sat all day with Dr. JMV from about 9am to 2:30pm. This experience was absolutely amazing and I'd like to split my thoughts into two areas: the physician-patient relationship and patient issues.

Dr. JMV saw about 15 patients with yesterday being a slow day. The nurses also handled a lot of routine, HIV negative patients while we were with him. My focus question going into this shadowing experience was: How does he maintain the physician-patient relationship while seeing so many patients? It didn't take long to see what made him special. He is sitting when the patient enters and shakes their hand, says hello, and gets down to business, but he is never rushed. His questioning style is one that is both deliberate and detailed, but also slow and intimate. He never wrote a word while the patients were speaking. He never interpreted or explained while the patients were talking to him. If a patient started talking again while he was writing his notes, he immediately put his pen down and sat back to face the patient. Each patient sat in the seat right next to his desk where the barriers were broken down. He never slouched, but leaned in to be closer and hear better. The Rwandan people are very stoic and quiet. They often talk without looking at you. The tone and volume of his voice matched that of each individual patient and he never forced eye contact. His focus was intense and it was clear that he was both physically and mentally present. For that time, as far as he was concerned, Nina and I were not in the room. After he wrote his notes, he explained the patient's complaints as well as the purpose of each medication. For every single patient.

The patient that I see when I close my eyes and think of that day was a young boy probably about nine or ten years old. Old white Nike gym shoes stained brown by the dry red dirt, long yellow shorts with the three familiar green stripes of ADIDAS running along the side, and a dirty gray t-shirt. He came to the clinic alone and I never asked where mom or dad were, there was really no need. This young boy spoke softly and looked down at his hands as he answered Dr. JMV's questions. This physician was patient and kind. He prodded the boy and leaned in to lock his eyes and ask his questions. This boy was going to begin ARV therapy and needed a few other medications for a cough. Dr. JMV wrote the script and then did something I've never seen a physician do for a child: he carefully, one by one, explained each medication by name. Directions and all and asked the boy questions to make sure he understood. I had to go to the doctor a few days before my trip and my mom still asks me if I need her to come along. I'm 23. He was about nine. Hmmm... I know that he is alone because of necessity, but this speaks to the ability of understanding treatment in pediatric patients. As a future physician specifically interested in children's Infectious Disease, I am greatly concerned with the doctor-patient relationship. Too often I see physicians talk over and around children directly to the parent while never truly acknowledging the actual patient. And we, as a medical community, are wanting to see children feel comfortable with trips to see the doctor to grow into adults who trust us and come to see physicians when necessary. Do we expect this relationship based on trust and understanding to happen via magic beans and fairy dust? This boy came in and was able to describe his symptoms in his own words, expressing himself in a very poised and eloquent way. Many people do not hold the expression of a child equal with that of an adult, but this is to do them a great injustice. This is not to say children are capable of the same maturity or level of understanding as an adult, but their voice and the words it speaks are important. Just as important as that of the parent. This is something I will encourage in my own patients. In fact, for the first five minutes, I would love to cover the parent's mouth with duct tape and only hear from the child. So many adults feel uncomfortable in the presence of the physician, enough so to deter them from going. I feel this is an attitude that must be changed, and even better, never developed. It comes from years of talking to the doctor, finding their voice and the right words to explain their problems. How can a mother or a father know if a child's pain is sharp or dull, pulsating or steady? They, themselves are not feeling it, they must be told. If parents are encouraging their children to speak to them about illness, why not encourage them to speak to the person responsible for treating them as well?
The patients feel so comfortable as children and adults seeing Dr. JMV that I was surprised at the ease with which shirts came flying off! A little boy came in with his mother had a very severe and painfully swollen case of shingles (think Brandon... sunburned...100 times worse). Truthfully, I've never seen a human being that shade of red before. And the whole area was covered with tiny, painful blister-like spots. Dr. JMV asked him what he was in for today and before I knew it, we were looking at a bare back and a little kid butt crack. Just like that. He never appeared embarrassed and he was never prompted to drop trow, but there he was, quite matter-of-factly. I see London, I see France...I saw a lot today.
While it's true that the Rwandan people are very serious in appearance, with little show of emotion this is not usually true at Dr. JMV's office nor at the WE-ACTx clinic. In these places pain is not hidden. Physical weakness is not covered. Concern is intensely expressed. Is this due to feeling relaxed in the physician's office? Partly. Dr. JMV is comforting, attentive. They let down their guard with him because he is respectful of their vulnerability. It has nothing to do with physical exposure. It has everything to do with emotional exposure. He moves and speaks slowly. He asks questions that can be difficult or stigmatizing to answer, but he does it in such a way, with such an emotional tenderness, that shows each patient he or she is loved. Unfortunately, this cannot be taught to medical students. Too often, this relationship is taken for granted or never cultivated to the level of trust and true partnership that it should be. When one has the opportunity to witness an encounter of such quality between a physician and a patient, it is truly both inspiring and humbling.
So, what's the other part? Simply stated, desire. Necessity. These people are very sick and very poor which makes for the most deadly combination. I love hearing people use the phrase, "Oh that's the worst. I hate that." Poverty and illness, whether it's malaria, dysentery, HIV, or TB, that's the worst; I hate that. No higher, I call. Patients know that, especially in resource poor settings, they have very limited time to spend with the doctor and that the waiting room is often overflowing with people just as sick as themselves, waiting to be seen. They are always waiting. To see the physician, to feel better, to find their next meal, to find work, to get their test results. Once inside the physician's office, Rwandans no longer wait. The second the doctor asks the first question, many patients speak with a fiery quickness, voices raised, emotional faces. They have come to see the doctor and there is no confusion about why they are there. Many patients don't acknowledge Nina and I. The ones who do, shake our hands, sit, and don't look at us until Dr. JMV begins to write. They are finished, and now, again have time to wait.