Friday, November 30, 2007
Mento Meditations
I munched on the Mento and a small hard lump started to roll about in my mouth. Bad candy, I thought, and spit it into my hand, only to see the amalgam gleam in the white enamel. Second molar I’ve fractured here in Derby, bookends to my year, and one more little reminder of my mortality. Another trip to the kindly overseas-trained Derby dentist who sets a temporary filling (at no charge). So we go, creaking and cracking and limping into the long slide down from midlife.“Why be upset about it?” Vicki says, “There’s nothing you can do about it. It could be a lot worse!” And she is right. By my age, her father had survived a major heart attack, CHF, and a bypass with experimental ventriculoplasty. It’s “just my idea”, as the Buddhists say, that I should somehow escape the vicissitudes of aging and disease. I wonder that my idea is even more strongly incorrect because I’m a doctor. I have practiced my detachment to the point that I won’t believe disease can happen to me. Especially since I take fairly good care of myself. Oh well, as the t-shirt says, “Eat right, exercise hard, live well, and die anyway…”
Our travel health insurance coverage ends the minute I step back onto U.S. shores next week, so we’ve been trying to figure out how to avoid becoming one of the 50 million or so uninsured U.S. citizens. Health insurance for my new post won’t cover me until January, so there is a month gap. This is not a big worry for little creaks and cracks, but we don’t want to risk suffering a major car crash or slip on the ice without coverage.
I contacted several people who recommended short-term health insurance. These policies are non-renewable beyond 6 or 12 months, and are designed for people between jobs. Just Google the term and tons of sites come up wanting to sell you a policy.
So I gamely spent an hour or two reading about this product on the web, and obtaining various quotes. Its almost as much fun as making airline reservations, there are so many combinations and permutations. First question is where do I live? I guessed I could pick any state I can make an argument for: there would be Iowa, which I left this year; Ohio, location of my mail drop at my parents, or Maine, ultimate destination. I decided to try Maine. Found a nice catastrophic policy at a cheap cost, and started answering questions.
Now it gets a bit dicey. There are “7 questions” one must answer “NO”, or you can’t be issued short-term insurance. Some are obvious- “do you have cancer?” But do I have “degenerative joint disease of the knee?” At first I use my doctor brain, and think, yes, because I had knee surgery for a torn cartilage. But then I rethink it with a consumer’s brain. I fell in the boat and hurt my knee, and after my surgery I walked 53 km over a 1000 meter mountain and back in New Zealand. So I decide I don’t really have DJD, and anyway, I’m not looking to stick the insurance company for a total knee surgery this month. So OK, we answer all the questions “NO”, put in our credit card number and hit the SUBMIT button. (This in itself is pretty scary, as the application obtains birth date, SSN, and enough details for any identity thief to have great fun. I am surprised that there are not a lot of phishing sites set up to collect this information from the unwary.)
Forty-eight hours later, through the miracle of email, my application is REJECTED. No reason given. But my guess is that it’s the MIB in action again! No, not the Men in Black, but the Medical Information Bureau (or some other ethereal insurance data base) which has recommended because of my age and past claims, I am unworthy of insurance at this low, low price.So I stayed up late one night and called Anthem Blue Cross in Maine, to ask about an individual (non-short-term) policy. Maine is one of the few states that require all insurance companies to insure all comers, without exclusions. But it turns out there is a catch- you must live in Maine for 60 days before you are eligible. So no joy with Blue Cross (which by the way would have cost over $1000 for a month of coverage for the two of us, IF we were eligible).
However, the Anthem guy was very helpful and did steer me to another short-term company, Assurant, which has a different set of exclusion questions. So I tried again, and this time was approved for a short-term policy, $1000 personal/$4000 family deductible, 80% copay (up to $10,000), lifetime max of $2 million coverage. This cost $350 for the month. But, God forbid, if we should get hurt, at least we won’t be bankrupted.
As many criticisms as I could make of the Australian health care system after this year, this experience does bring home one major difference in which the Australians are far ahead of the U.S. No one in Australia has to worry that if they have a head injury, or come down with leukemia, or choke on a piece of steak, their life’s savings will disappear into the black hole of healthcare.
This is just crazy. We Americans should tell our congressmen to support The United States National Health Insurance Act (HR676)
Universal Medicare coverage would give every American citizen a “fair go” (as they say here in Oz).
Friday, November 23, 2007
Thanksgiving Day
It is the end of the Rural Clinical School year. I am in Perth for meetings and exams, saying goodbye to all our RCS students as well as my fellow RCS Coordinators. And I am a happy man. I have so much to be thankful for. I won’t list everything- it would take me all day. But after living in Australia for a year, Thanksgiving Day has a special poignancy.
Frozen turkeys in Perth run about AU$ 38 for a 12 pound bird (AU$ 69 for same size in Derby!), so we opted to have “Thanksgiving Breakfast” Friday morning at Miss Maud’s Swedish Buffet downtown. With time differences, it was still evening of Thanksgiving in the U.S., and we both love breakfast, so this seemed perfect. Miss Maud’s is in the Swedish Hotel, and has already been decorated for Christmas. It was very charming. We enjoyed Swedish pancakes, wonderful breads and fruit with muesli. While we were relaxing, the couple next to us overheard us talking and struck up a conversation about Australia. As soon as we open our mouths here, anyone can guess we are American. (But to be politic, they ALWAYS guess “Canadian” first, because apparently our Northern neighbors are quite offended to be lumped in with us Yanks).
These nice people wondered how we liked Perth. But as we talked, it turned out they were Kiwis. Not only that, they were just back from visiting New Zealand. And to top it off, they were from Winton. Not only FROM Winton, but both BORN there.
Which brings me to the soon-to-retire Head of School, my boss this year, Campbell Murdoch, and his theory of causality. Campbell tells me that he deeply feels that things don’t just happen by coincidence. Certainly one of the things I’m most thankful for this year, is the opportunity to work for Campbell and be part of the wonderful team of RCS faculty. This opportunity came about due to a “chance” meeting he had with our mutual friend and former Winton practice nurse, Dawn, when a plane was delayed in a New Zealand airport 18 months ago. She told Campbell of my interest in Australia, gave him my e-mail address, and the rest is now history. {picture of Campbell, in center at right, with Port Hedland MC and students}
Campbell and Annie visited us in Derby midyear, and have been concerned and supportive of us all year. I’ve realized how much I’ve missed talking with an older, wiser, doctor in recent years. As I age, opportunities to talk to someone like Campbell become more rare and precious. (I’m not sure he was very happy with my expressed appreciation of his ancient wisdom.)
Although I don’t see the other RCS Site Coordinators and Faculty daily, we have regular meetings, and communicate with daily e-mail, and fortnightly video conferences. The 5 central meetings we’ve had this year provide enough opportunity for personal interaction that I’ve made great friendships among the faculty. I am thankful for all that I have learned from them. This extends from a basic understanding of medical education in Australia, to tips about Aboriginal health, to understanding the rules of “footy” and cricket. They have also been very interested in what I have to say. And, they have been most patient when I’m sure I’ve put my foot into it and said something offensive or off-target.
I believe it is unfortunate that so many American doctors lack experiences in foreign medical settings. I very much admire my faculty friends for their diverse backgrounds and the experiences they bring to the RCS. Like the local doctors in Derby, many of them are OTDs, and bring an international perspective to the RCS’s medical education from places such as England, Scotland, and South Africa. One is a Rhodes Scholar, and all have fascinating stories to tell. Added to the RCS’s home-grown faculty, who often have extensive overseas experiences in places like Papua New Guinea, the RCS fields a strong team. All of them have been or are practicing country doctors. As I helped with the OSCEs in urban Perth yesterday, and met the suit-and-tied Urban UWA faculty, I was struck by what a different bunch we RCS teachers are with our relaxed, blue-jeaned, practical, at-the-coalface approach to medicine, and to people in general.
Campbell talks about the RCS as being a family-friendly organization, but it is much more. It is a true family, engaged in the generative process of raising our “children” to be good doctors. And today I am thankful to have been accepted into this family this year. I will miss them so much. Vicki and I cannot bear to really say goodbye to them, so we leave them with invitations to visit us in Maine for “lobster rolls and whoopee pies” (a tribute to the kind of humorous innuendo that Campbell so enjoys).
The Professor has built a great team by including people in a meaningful endeavor that is larger than themselves. He does this with humility, humor and joy. He possesses a charisma I’d heard about from many people in Winton, but had to experience to fully understand. I see Campbell accepting and acknowledging the value, beauty and worth of every human being he meets. (This is how he gets away with a kiss and a hug with all the women, without ever getting slapped.) And he and I are both very lucky to be supported by strong, patient women, who have been willing to go places that most doctors’ spouses would never consider. Fate has provided Campbell with his Annie, and me, with Vicki; and I know that, of all things in our lives, we are both most thankful for that.
Campbell, as he leaves his 5 years as Head of the RCS, admonished us with his “two rules” for success. First, “don’t ever become respectable” because respectability deprives you of the ability to grow, progress and change life for the better. And the other rule is that when others tell you “you must do it this way”; or worse, “it can’t be done”; tell them to “bugger off”. (To get the full effect, say it again—this time in a deep Scottish accent… “BUGGER OFF!”).
A few weeks ago I wrote about fate, but spending a few days with Campbell and the RCS faculty has made me rethink my attitude. Certainly fate exists and must be dealt with. But I find myself more positive about it this week. We can deal with fate by building relationships with people who center on positive, generative endeavors. By doing this, we imbue our lives with meaning and purpose. And for this, and the opportunity to learn this from the RCS, I am forever thankful.
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| Click to see Album |
These nice people wondered how we liked Perth. But as we talked, it turned out they were Kiwis. Not only that, they were just back from visiting New Zealand. And to top it off, they were from Winton. Not only FROM Winton, but both BORN there.
Which brings me to the soon-to-retire Head of School, my boss this year, Campbell Murdoch, and his theory of causality. Campbell tells me that he deeply feels that things don’t just happen by coincidence. Certainly one of the things I’m most thankful for this year, is the opportunity to work for Campbell and be part of the wonderful team of RCS faculty. This opportunity came about due to a “chance” meeting he had with our mutual friend and former Winton practice nurse, Dawn, when a plane was delayed in a New Zealand airport 18 months ago. She told Campbell of my interest in Australia, gave him my e-mail address, and the rest is now history. {picture of Campbell, in center at right, with Port Hedland MC and students}Campbell and Annie visited us in Derby midyear, and have been concerned and supportive of us all year. I’ve realized how much I’ve missed talking with an older, wiser, doctor in recent years. As I age, opportunities to talk to someone like Campbell become more rare and precious. (I’m not sure he was very happy with my expressed appreciation of his ancient wisdom.)
Although I don’t see the other RCS Site Coordinators and Faculty daily, we have regular meetings, and communicate with daily e-mail, and fortnightly video conferences. The 5 central meetings we’ve had this year provide enough opportunity for personal interaction that I’ve made great friendships among the faculty. I am thankful for all that I have learned from them. This extends from a basic understanding of medical education in Australia, to tips about Aboriginal health, to understanding the rules of “footy” and cricket. They have also been very interested in what I have to say. And, they have been most patient when I’m sure I’ve put my foot into it and said something offensive or off-target.
I believe it is unfortunate that so many American doctors lack experiences in foreign medical settings. I very much admire my faculty friends for their diverse backgrounds and the experiences they bring to the RCS. Like the local doctors in Derby, many of them are OTDs, and bring an international perspective to the RCS’s medical education from places such as England, Scotland, and South Africa. One is a Rhodes Scholar, and all have fascinating stories to tell. Added to the RCS’s home-grown faculty, who often have extensive overseas experiences in places like Papua New Guinea, the RCS fields a strong team. All of them have been or are practicing country doctors. As I helped with the OSCEs in urban Perth yesterday, and met the suit-and-tied Urban UWA faculty, I was struck by what a different bunch we RCS teachers are with our relaxed, blue-jeaned, practical, at-the-coalface approach to medicine, and to people in general.Campbell talks about the RCS as being a family-friendly organization, but it is much more. It is a true family, engaged in the generative process of raising our “children” to be good doctors. And today I am thankful to have been accepted into this family this year. I will miss them so much. Vicki and I cannot bear to really say goodbye to them, so we leave them with invitations to visit us in Maine for “lobster rolls and whoopee pies” (a tribute to the kind of humorous innuendo that Campbell so enjoys).
The Professor has built a great team by including people in a meaningful endeavor that is larger than themselves. He does this with humility, humor and joy. He possesses a charisma I’d heard about from many people in Winton, but had to experience to fully understand. I see Campbell accepting and acknowledging the value, beauty and worth of every human being he meets. (This is how he gets away with a kiss and a hug with all the women, without ever getting slapped.) And he and I are both very lucky to be supported by strong, patient women, who have been willing to go places that most doctors’ spouses would never consider. Fate has provided Campbell with his Annie, and me, with Vicki; and I know that, of all things in our lives, we are both most thankful for that.
Campbell, as he leaves his 5 years as Head of the RCS, admonished us with his “two rules” for success. First, “don’t ever become respectable” because respectability deprives you of the ability to grow, progress and change life for the better. And the other rule is that when others tell you “you must do it this way”; or worse, “it can’t be done”; tell them to “bugger off”. (To get the full effect, say it again—this time in a deep Scottish accent… “BUGGER OFF!”).
A few weeks ago I wrote about fate, but spending a few days with Campbell and the RCS faculty has made me rethink my attitude. Certainly fate exists and must be dealt with. But I find myself more positive about it this week. We can deal with fate by building relationships with people who center on positive, generative endeavors. By doing this, we imbue our lives with meaning and purpose. And for this, and the opportunity to learn this from the RCS, I am forever thankful.
Thursday, November 22, 2007
Walking Away From Perth
Perth is beautiful in the early summer. We are here for my last RCS faculty meetings and the students’ Final OSCEs. Flying in the other day we looked down and saw huge blooming clouds of purple jacaranda trees. The roses are all in bloom and the cities has a fresh-scrubbed feel, like it’s straight from an early morning shower and shave. Steel towers soar over their reflections in the Swan River and no one is seen sleeping in the meticulously manicured parks or wandering homeless in the streets.Andrew, one of the Coordinators, currently practicing in Kalgoorlie, is hitching a ride with me back to the hotel, when we get to talking about this. He and his wife practiced in Derby over 10 years ago. “When I first came back to Perth” he says, “for two weeks I just wanted to open the window and shout at everybody ‘Don’t You Know What is Going on Up North?!’ “. He found the contrast between the communities so outrageous that he could hardly stand it. It is a larger culture shock to travel from Derby to Perth than it would be to go to China or India, because the two places are such universes apart.
Vicki and I observe Perth through very different eyes, compared to last January. This Sim-perfect-City is just as beautiful, clean, neat and tidy as it was then. I’m sure its one of the most pleasant and comfortable cities on Earth, with its cool green spaces, tidy urban planning and gorgeous Indian Ocean beaches. But we both feel we could not be comfortable living here anymore, knowing what we know now. It is a moral conundrum. I am reminded of Ursula LeGuin’s little story, The Ones Who Walk Away From Omelas. In that moral fairy tale people live in a perfect village, in peace and prosperity. But this perfection is maintained by an unbreakable magic spell, which requires one small child to live in hideous degradation in the deepest basement of the town. The dark power of this child’s misery prevents the entire town from sliding into chaos, filth, pestilence and mayhem. Everyone in the town learns this is the case when they come of age. And from time to time, a lone figure will walk away from the town, never to return.The place they go towards is a place even less imaginable to most of us than the city of happiness. I cannot describe it at all. It is possible that it does not exist. But they seem to know where they are going, the ones who walk away from Omelas.LeGuin poses the question: “Are you, the reader, one who would also walk away?”
This is a question I can’t shake, as I walk around Perth, with the dust of Derby still on my shoes. How might I walk away from Omelas? And am I sure, really sure, that the spell is truly unbreakable?
Saturday, November 17, 2007
Valedictory
As a teacher in the RCS, I have a wide variety of roles. Foremost, I am the coordinator of the students’ learning, organizing their clinical attachments to the wards, clinics and remote sites and working to get them to the bedside as much as possible. But at various times I’m also a mentor, friend, colleague, preceptor, examiner, spirit guide and at times, a bit in loco parentis. Which means, either “in the place of the parent” or “in crazy parent mode”, I’m not sure which.
When people here have asked me about the differences between medical students in the U.S. and Australia, I have noted that the students here are very young. Most of the UWA RCS students begin medical school at age 17, right out of high school. Some have come back at older ages, but most have little life experience compared to a U.S. post-graduate. In fact, at the Jarlmadangah weekend last February, only 2 out of 17 students were able to well articulate “why they wanted to become a doctor” after 4+ years of study. Medical school in Australia is heavily subsidized. Compared to the rest of the world it is damn near free. (The low tuitions can be deferred to built-in interest-free loans, and graduates move on to full-salary post-graduate training placements, unlike the U.S. where Residents are paid at about 1/4 of usual salaries. In addition there are many scholarships and loan-forgiveness schemes as well.) Many of the students are eligible for Centrelink (welfare) subsidies while they are full-time students. In addition, RCS students receive free housing, transport of possessions and their own cars to remote sites, use of the RCS 4WD vehicle (free petrol included) “for educational purposes” and an additional stipend for the costs of rural living. They receive free airfare to and from their sites, and one free trip back to Perth for the Options study period mid-year. Student housing comes with free high speed internet, a complete library of medical books on site, as well as unlimited access to all University Library electronic books and journals. All their cases, lectures and slide talks are downloadable from the medical school web site. Student houses, generally some of the nicest in any remote town, are fully equipped, including TVs, stereos, DVD players, and modern kitchen and laundry appliances. The Port Hedland house even has a swimming pool. Gardening services are provided by the site—students don’t even have to mow the grass.
I spent this last week doing last minute tutorials with my RCS students, who have Final Exams this coming week. I’ve also welcomed my replacement coordinator, just arrived from the U.K., as well as supported our new Resident doctor who has been here one week. Last weekend the RCS students took us out for dinner, gave my assistant Jane, and me some lovely parting gifts, and came to a farewell reception we held for them at DAHS.
Finishing up my student teaching has led me to reflect quite a lot, because, after 20 years of having students in one form or another, I plan to take some time off from teaching for at least a year or two. In their individual exit interviews, the RCS students all expressed great appreciation for the year, and commented on how much they’d grown and improved as self-directed learners. All three of them commented in one way or another on Aboriginal health, the gist being that “before this year, they thought of Aboriginal people as being very different, but now they see they are just people with common human problems, complicated by different backgrounds”. Hearing this spontaneously from each of them has to have been one of the high points of the year.
While it is easy to teach shoulder examinations, the role of the folic acid cycle in Wiernicke’s encephalopathy, and stepped care plans for asthma, it is much harder to teach the personal and professional side of medicine. I can only do that by modeling, discussing cases, and providing environments where “transformational learning” might occur. At the end of the day, my goal as a teacher is not to produce “good-enough doctors”, but to nurture doctors who are good at what they do and good as people. I hope all the RCS students graduate with as much empathy, compassion and kindness as they possess smarts. Maybe more. One can always learn the smarts.
Without going into details, my students’ final leave-taking was not without its major bumps, causing a bit of consternation around here this week. Other concerning incidents have occurred this year across the RCS and also among the 6th-year students. For example, one 6th-year student's mother called the Medical School less than 10 hours after her arrival in Derby complaining that her 23 year old daughter’s hospital quarters were dirty and had cockroaches. This occurred in a community where many people live outside in the parks, or 15-20 people reside in one family house. In fairness, I have concerns about all medical students—not only in Australia, but in the U.S. as well. The stats show that more and more, the privileged are recruited into medicine, while fewer students with rural and social disadvantaged backgrounds become doctors every year. [be sure to read the "Response from Australia" on the link above]
So I have been wondering, do the students generally appreciate all the advantages they receive? Do they truly know how lucky they are to have this education, and all the material, not to mention personal and professional, support they enjoy?
Much of this week, my thoughts have gone back to the shy, teenaged Aboriginal girl from the desert beyond Hall’s Creek, who after 3 days on the Leeuwin trip in July, finally got up the courage to talk to Vicki, and shared her dreams of becoming an astronaut. She has been handicapped by birth and circumstance—such aspirations are forever out of her reach. How much would she give to trade places with any one of our medical students in the RCS?
Last January on the first day my students arrived in Derby, Vicki and I made supper for them and talked about the year ahead. Vicki talked about the importance of hygiene in the tropics—that kitchens and baths must be kept clean to prevent disease, that hygiene must be much more of a way of life here in the heat, due to risks of bugs, parasites, and skin infections. And I asked them, when on the wards or in the office, to wash their dishes. Because students and doctors are not special people, they should show humility, respect for co-workers and self-regulation by cleaning up after themselves, and not expecting to be waited upon. (And of course, behind my admonition is one of my favorite Zen koans: Student: “What is the way to enlightenment”? Master: “Go wash your rice bowl!”)
What do I want to see in the next generation of doctors—the people who will take care of me when I am old and sick and dying? Like everyone, I want a doctor who is kind and caring. A doctor who walks the talk, who takes care of herself with discipline and self-regulation, because she knows she herself is the tool that facilitates healing. I want a doctor who not only washes his own bowls and cups, but one who sees the wider problems, the big picture. So maybe, if I had to do it over again, I would assign, near the beginning of the year here in Derby, a reading and discussion of LeoTolstoy’s little treatise about poverty and morality, “What Then Must We Do?”
It is a hard question. It is what we must teach our children, the next generation, to whom we are leaving a world in trouble. How do we privileged doctors relate to our less privileged patients? How does the developed world fairly treat the undeveloped under Kyoto protocols? How do we as rich Westernized countries deal with poor, war-torn nations? It is a question of self-control, self-regulation, self-discipline and self-denial. Where do we draw the lines for acceptable and expected behavior? I don’t have all the answers.
But despite the bumps here at the end of the year, I leave teaching feel satisfied that at least I have asked the questions of my students. And I know that they have heard what I am saying.
When people here have asked me about the differences between medical students in the U.S. and Australia, I have noted that the students here are very young. Most of the UWA RCS students begin medical school at age 17, right out of high school. Some have come back at older ages, but most have little life experience compared to a U.S. post-graduate. In fact, at the Jarlmadangah weekend last February, only 2 out of 17 students were able to well articulate “why they wanted to become a doctor” after 4+ years of study. Medical school in Australia is heavily subsidized. Compared to the rest of the world it is damn near free. (The low tuitions can be deferred to built-in interest-free loans, and graduates move on to full-salary post-graduate training placements, unlike the U.S. where Residents are paid at about 1/4 of usual salaries. In addition there are many scholarships and loan-forgiveness schemes as well.) Many of the students are eligible for Centrelink (welfare) subsidies while they are full-time students. In addition, RCS students receive free housing, transport of possessions and their own cars to remote sites, use of the RCS 4WD vehicle (free petrol included) “for educational purposes” and an additional stipend for the costs of rural living. They receive free airfare to and from their sites, and one free trip back to Perth for the Options study period mid-year. Student housing comes with free high speed internet, a complete library of medical books on site, as well as unlimited access to all University Library electronic books and journals. All their cases, lectures and slide talks are downloadable from the medical school web site. Student houses, generally some of the nicest in any remote town, are fully equipped, including TVs, stereos, DVD players, and modern kitchen and laundry appliances. The Port Hedland house even has a swimming pool. Gardening services are provided by the site—students don’t even have to mow the grass.
I spent this last week doing last minute tutorials with my RCS students, who have Final Exams this coming week. I’ve also welcomed my replacement coordinator, just arrived from the U.K., as well as supported our new Resident doctor who has been here one week. Last weekend the RCS students took us out for dinner, gave my assistant Jane, and me some lovely parting gifts, and came to a farewell reception we held for them at DAHS.
Finishing up my student teaching has led me to reflect quite a lot, because, after 20 years of having students in one form or another, I plan to take some time off from teaching for at least a year or two. In their individual exit interviews, the RCS students all expressed great appreciation for the year, and commented on how much they’d grown and improved as self-directed learners. All three of them commented in one way or another on Aboriginal health, the gist being that “before this year, they thought of Aboriginal people as being very different, but now they see they are just people with common human problems, complicated by different backgrounds”. Hearing this spontaneously from each of them has to have been one of the high points of the year.
While it is easy to teach shoulder examinations, the role of the folic acid cycle in Wiernicke’s encephalopathy, and stepped care plans for asthma, it is much harder to teach the personal and professional side of medicine. I can only do that by modeling, discussing cases, and providing environments where “transformational learning” might occur. At the end of the day, my goal as a teacher is not to produce “good-enough doctors”, but to nurture doctors who are good at what they do and good as people. I hope all the RCS students graduate with as much empathy, compassion and kindness as they possess smarts. Maybe more. One can always learn the smarts.
Without going into details, my students’ final leave-taking was not without its major bumps, causing a bit of consternation around here this week. Other concerning incidents have occurred this year across the RCS and also among the 6th-year students. For example, one 6th-year student's mother called the Medical School less than 10 hours after her arrival in Derby complaining that her 23 year old daughter’s hospital quarters were dirty and had cockroaches. This occurred in a community where many people live outside in the parks, or 15-20 people reside in one family house. In fairness, I have concerns about all medical students—not only in Australia, but in the U.S. as well. The stats show that more and more, the privileged are recruited into medicine, while fewer students with rural and social disadvantaged backgrounds become doctors every year. [be sure to read the "Response from Australia" on the link above]
So I have been wondering, do the students generally appreciate all the advantages they receive? Do they truly know how lucky they are to have this education, and all the material, not to mention personal and professional, support they enjoy?
Much of this week, my thoughts have gone back to the shy, teenaged Aboriginal girl from the desert beyond Hall’s Creek, who after 3 days on the Leeuwin trip in July, finally got up the courage to talk to Vicki, and shared her dreams of becoming an astronaut. She has been handicapped by birth and circumstance—such aspirations are forever out of her reach. How much would she give to trade places with any one of our medical students in the RCS?
Last January on the first day my students arrived in Derby, Vicki and I made supper for them and talked about the year ahead. Vicki talked about the importance of hygiene in the tropics—that kitchens and baths must be kept clean to prevent disease, that hygiene must be much more of a way of life here in the heat, due to risks of bugs, parasites, and skin infections. And I asked them, when on the wards or in the office, to wash their dishes. Because students and doctors are not special people, they should show humility, respect for co-workers and self-regulation by cleaning up after themselves, and not expecting to be waited upon. (And of course, behind my admonition is one of my favorite Zen koans: Student: “What is the way to enlightenment”? Master: “Go wash your rice bowl!”)
What do I want to see in the next generation of doctors—the people who will take care of me when I am old and sick and dying? Like everyone, I want a doctor who is kind and caring. A doctor who walks the talk, who takes care of herself with discipline and self-regulation, because she knows she herself is the tool that facilitates healing. I want a doctor who not only washes his own bowls and cups, but one who sees the wider problems, the big picture. So maybe, if I had to do it over again, I would assign, near the beginning of the year here in Derby, a reading and discussion of LeoTolstoy’s little treatise about poverty and morality, “What Then Must We Do?”
It is a hard question. It is what we must teach our children, the next generation, to whom we are leaving a world in trouble. How do we privileged doctors relate to our less privileged patients? How does the developed world fairly treat the undeveloped under Kyoto protocols? How do we as rich Westernized countries deal with poor, war-torn nations? It is a question of self-control, self-regulation, self-discipline and self-denial. Where do we draw the lines for acceptable and expected behavior? I don’t have all the answers.
But despite the bumps here at the end of the year, I leave teaching feel satisfied that at least I have asked the questions of my students. And I know that they have heard what I am saying.
Sunday, November 11, 2007
A Fate-full Flight
I am on a remote flight up the Gibb River Road, when the last patient comes into the clinic. She has been dealing with domestic violence at home for quite awhile, and requests that I fly her and her 4 preschool children back to Derby on the plane. The smallest is a nursing infant in her arms. She tells me her partner has often threatened to kill her. And this morning, he told her to get everyone out off the house. She has no relatives in the community or any place to live.The local area nurse is concerned, but doesn’t really know what to do. I listen to the young woman for awhile; give her the message “No one deserves to be treated this way”, talk to her about the safety of her kids, explore her perceptions that she has no options. I ask her to wait a bit, and phone the Aboriginal Corporation for Women’s’ Assistance service in Derby. No one answers the telephone. The emergency mobile number gives me the message that it is “no longer in service”. And there are no police services on the Gibb River Road. (Heck, there are no police in Derby after 5PM. If someone is being murdered down the street, you may call and get Broome Police dispatch, who will send someone around in the morning.) In desperation I call our Social Emotional Well-Being (SEWB) counselor at DAHS and talk to her. She thinks she can find the Women’s’ Assistance worker, so I wait a bit.
During all this, the partner comes back to the clinic and asks my patient and the kids if she would like him to fix lunch for them? They all troop off together. While I’m waiting for the SEWB call back, I eat my own PB&J. I’m worried. How would I feel if I fly off and something bad happens? Yet the single-engine plane is very light, and it’s really not appropriate to carry the infants without proper seating. (It’s a hot and very bumpy day up there.)
The SEWB worker calls back: “No joy”. I’m on my own. The patient comes back after lunch and seems less anxious. I review her options again. I talk to her about coming to the clinic to make a police report if she feels in imminent danger. She doesn’t want to do that now. I talk about having the traveling counselor see her when they come up the Gibb in a few weeks. She’s pretty sure she doesn’t want that either, but I prevail on her that I will put in the referral, and she can always decide she is ok later. She seems satisfied and leaves. I wonder, was this just a ploy for a flight to Derby? Is she just conflicted and unhappy and needing someone to talk to? Has my advice helped? Have I misjudged the situation in any way? The cultural divide never has seemed so wide.
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The season is changing. Besides the daily 40 C temperatures, we now have clouds, and afternoon flights require tight seatbelts to avoid hitting my head on the up and down drafts. We fly home at 8500 feet, just beneath the flat bottoms of fluffy cumuli. It has rained 2.5 cm up the Gibb, and I again look down into remote gorges with huge white waterfalls. The rainfall has stimulated the grass and things are green in the Gibb, although still sere and dry in Derby. One community puts a herd of horses out on the schoolyard to “cut the grass”.
It is Spring here, but that makes no difference to the ubiquitous dogs in the communities. They have puppies all year around. Here is one of our nurses, Mary Jane, a Sister of Mercy, with a new pup.Which brings me to the issue of sainthood. The Remote Area Nurses (RANs) in Australia are excellent candidates in my view. Whether they are religious or secular, they live and work in many remote Aboriginal communities. They are essentially on call 24/7 for any accidents, of which there are many. And they do the best they can, with help only from RFDS by phone or hours-away flights. They know the people in the community, and do their best to educate them to do the right things. But they need tremendous patience to see that advice ignored day after day, year after year. And they risk “payback” from families if there is misperception about any adverse outcome in the clinics. It is not a job for the fainthearted. They are heroes in my eyes.
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I was thinking about heroism on my flight home this week. Lately I’ve heard a lot of stories from people who have been faced with insufferable situations. A mom adopts a child who develops homicidal thoughts and actions towards her. My patient with children is stuck in a situation with domestic violence. A family is faced with institutionalizing their autistic kid. A patient is diagnosed with cancer. Usually these are problems involving birth, life, love and death.
Several of my correspondents have intimated that my motives for this year abroad have been similarly heroic and altruistic. This feels very false to me. As we turn into the last 4 weeks here, I have looked back to my first post on this blog, a year ago. We were in a metamorphosis at the time. A sea change. Not a choice.
What is the choice when facing an impossible unsolvable problem? There is no choice. One just gets stubborn and pushes on through as best one can.
Yet, from the outside, there is a tendency to ascribe noble aspirations, heroic qualities to the people involved in the story. Only in fairy tales do we find heroes who choose to face danger voluntarily. In fairy tales the hero wins, despite all odds. Contrast them to the great myths, where Fate controls the outcome, often to the hero’s detriment.
When I was 17, I talked to one of my first physician mentors about the Lord of the Rings books, which I had just read for the first time. He commented that their cult status (at that time) was due to the well-written human qualities of the Hobbits. So I am reminded of one passage in the books, where Sam breaks the 4th wall in the narrative, and speculates that later generations will “tell heroic stories about Frodo and his faithful gardener, Sam”. He notes that the storytellers won’t relate that he and Frodo were in a situation where they just did what they had to do.
Fate and destiny certainly rule here in the Kimberly. People here seem to live in the present more than Westerners. The future is uncertain, uncontrollable, inevitable. The little boys I see here in the clinic hold still for me to look in their ears, poke sticks down their throats, give them injections. As 3 and 4 year olds, they are already stoics.
I think we Westerners fool ourselves about controlling our lives. We can try to choose who to be with. Where to work. Try to find pleasure by finding satisfaction in our actions, whatever they are. But our choices are limited. In the end, things happen, and we must grow or die.
And as I fly over these ancient rocky landscapes, I reflect that they will never transform into rich farms, great cities, or green golf courses. Fate holds sway.
Wednesday, November 07, 2007
Aboriginal Health Summit
I’ve not been feeling very well for about 6 weeks now. First I had the flu, and sinus infection. Getting over that, I developed pain in my right shoulder. This impingement got so bad that I’ve had to stop all swimming with my arms. I am reduced to kicking with the float boards which is very frustrating. And to top it off, in Port Hedland I got bitten by sandflies, and about 4 days later developed a serious case of papular urticaria. The itching has been so bad that I sleep only by taking 50 mg of Benadryl and taking an ice pack to bed with me. The antihistamine makes me hung over until about noon each day. So I am not my usual perky self. The good news is that my students passed their OSCE’s. This week we are having final tutorials before they leave Derby next week for final exams in Perth.Last week was the Aboriginal Health Summit in Broome. I stopped and attended for a couple of days on the way back from Port Hedland.
Two talks caught my attention.
First, a talk by an architect, Paul Pholeros talked about housing and health in Aboriginal communities. The prevailing Australian prejudice is that “Aboriginal people are given free houses that they don’t take care of, and in fact actively destroy”. Even my hairdresser here in Derby repeated this attitude to me this week. The truth, based on surveys of 5232 Aboriginal homes, is that only 10 percent of 91,819 items in these homes were damaged by overuse, misuse, abuse or vandalism. A much bigger problem is that 70% of repairs were needed for shoddy or incorrect initial construction. The remainder of problems were due to the harsh Outback environment. Outside of urban areas, most water in Australia is very high in mineral salts, which results in rapid corrosion of tap seats, for example.
In one community, 40 of 76 hot water units fitted in a government program were leaking due to a manufacturing fault, yet warranty claims were not honored. In essence, government housing programs put in very expensive housing- up to $AUD 400,000 per Outback home- which goes to the lowest bidder and results in a sub par construction that does not last. As a result, in many Aboriginal communities, only 33 % of homes had a working shower, only 55% a functional toilet, over 90% had unsafe electrical systems, and over 95% did not have a functional kitchen where food could be stored, prepared and cooked. Is it any wonder that poor nutrition, skin diseases, and diarrhea and respiratory diseases run rampant?Mr. Pholeros is part of a project in South Australia called HealthHabitat. They go into a community and teach the local people to survey, then repair the problems. His plea was that it is much cheaper to build homes correctly the first time, and provide local people with skills, tools and supplies to maintain the homes. Their program focuses on improving housing to promote the Nine Healthy Living Habits. Just fixing the water systems in one community saved $AUD 67,000 in water bills and over 100 million liters of water in this arid country.
Unfortunately, in 2006 the Minister for Indigenous Affairs could not account for how more than $AUD 2 BILLION had been spent on housing in the previous decade.
Perhaps a new government will spend the money more wisely? Mr. Pholeros has been researching and writing about these issues since 1993. He is the soul of persistence.
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The second story was about an Aboriginal community, Baryulgil, in New South Wales. These people were able to keep their land and preserve their culture. They were even lucky enough to find jobs on their land, mining a valuable natural resource. Unfortunately, this resource was asbestos. A similar story unfolded in Western Australia around Wittenoon and Roeburn. The presentation was focused on efforts to gain the communities’ trust. In one community, the son of the chairman went to University and studied anthropology and oral history collection. He has been hired to interview the old peoples’ stories about the mines, in order to collect data for compensation. This is needed, because the company that ran the mines, James Hardie, suffered “mysterious fires” that burned only the file cabinets containing the personnel health records of the miners. Also, the original chest x-rays of all these workers were sent off for review by the company, and also “disappeared” from the face of the Earth. While a settlement was negotiated two years ago, the company has not paid a cent yet to victims. When I shared this story with my mentor, Dr. David Atkinson, he said, “The irony around Aboriginal health never ends.” Barristers plan to bring new test cases to the courts.
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Finally, the newly released draft drinking guidelines for Australia are getting a bit of press here. Most of the controversy is not about the science or safety of the guidelines, but whether they are "realistic".
Labels: Aboriginal Health
Sunday, November 04, 2007
Elections, Ozzie Style
I am relaxing at the pool at the students' house in Port Hedland, after a long day doing OSCEs and talking with Stephanie, who asks, "What do you think of Hillary?"
It turns out her boyfriend is a law student and obsessed with U.S. politics. They both watch "The West Wing" but admit they understand as much about American politics as they do "gridiron". I tell her I feel out of the loop, living in Derby. We only see little snippets on World News Australia on SBS. We saw Hillary getting pounded at the debate by Obama and Edwards this week, but I have not had the opportunity to read much or understand any candidates’ positions. And since we are not returning to Iowa, I don't feel the need to make the effort just yet. I explain to Stephanie about the Iowa caucuses. And she answers my questions about the current Australian election. Or at least tries hard to. To me, it’s a bit like trying to understand the arcane rules of cricket.
John Howard, the current Prime Minister, dissolved his government 3 weeks ago, and has 3 more weeks of campaign before Election Day. Howard is a Liberal, which here, means really a conservative. He has been in power for 12 years. And I do mean in power. Under the Australian parliamentary system, the government with the majority (or a coalition with the majority) chooses a Prime Minister, who appoints members of the lower legislative house as Cabinet Ministers. So the legislative branch of the government also becomes its executive branch. This means they can run the country however they like, as their majority will pass any law or support any policy of the "executives". Imagine if the party controlling the U.S. House of Representatives automatically won the Presidency every time, and you will get the picture. No vetos. No fights between the Congress and President over legislation. (Oh, yes, I forget, we had that in the U.S. under Bush until the Democrats returned the country to a saner form of government last year!) So the genius of our Founders is revealed. They understood the need for checks and balances to keep the government from doing crazy things.
Australia has a different flavour to its democracy. The party in power gets things done alright. And after awhile, variable in time, the public gets sick of them and replaces them with the other party. This year, that looks to be Labour, who might be analogous to the U.S. Democrats, except that labour unions still play a role here, and Labour does not have the natural pull for the affluent and well-educated people that the Democrats traditionally held (but maybe not any more?). I am no political scientist, that is for sure, and I suspect that trying to draw analogies is like saying, "kangaroo hold the same place in the Australian ecosystem as deer in North America, except that they tolerate dry climates much better, oh and they have their babies without placentas, carry them in pouches, and don't have to worry about large predators once they grow to adult size". Things just don't cross-map well.
Add to that the smaller parties. The most important one seems to be the National Party, a rural issues group especially strong here in WA, which is in coalition with the Liberals. There are also the Greens, Family First, Australian Democrats and many others. The Greens hold 4 seats in the Australian Senate, and are contenders there for controlling the balance of power. (The Senate, as in the U.S. contains the same number of members from each Australian State, and is intended to balance the representation of the Lower House, which is proportional to population.)
I have to smile at the names of the many minor parties here, including the Australian Fishing & Lifestyle Party, the Four Wheel Drive Party , HEMP (Help End Marijuana Prohibition) , the Lower Excise Fuel and Beer Party , the unfortunately defunct Sun Ripened Warm Tomato Party, the Non-Custodial Parents Party, and the What Women Want (Australia) party.
I have to smile at the names of the many minor parties here, including the Australian Fishing & Lifestyle Party, the Four Wheel Drive Party , HEMP (Help End Marijuana Prohibition) , the Lower Excise Fuel and Beer Party , the unfortunately defunct Sun Ripened Warm Tomato Party, the Non-Custodial Parents Party, and the What Women Want (Australia) party.
Finally, add to this broth, the requirement that voting is MANDATORY for all Australians and that voting is preferential, and it makes for a confusing and fun time. All Australians face a fine if they don’t vote in the upcoming election. And this week, blinded judges picked numbered balls twice to assign positions on each ballot. The ballots themselves are paper and huge. And because they require each voter to number every single candidate in order of preference, 
I understand most Australians pick up a “cheat sheet” from their party of preference to copy in the voting booth. This means, that even if the Greens have no chance of taking a seat in a district, say, Bennelong where the Prime Minister is standing for re-election, their recommended preferences may make a huge difference in the ultimate winner. And there is a chance that Mr. Howard’s party might win the election while he loses his own seat in his Sydney suburb. This would catapult the unloved Peter Costello, his current Treasury Minister, into prematurely becoming the next Prime Minister. Counting the votes, all done on paper ballots, is very complex. Wikipedia has a good article on preferential voting in Australia if you are interested in the details. And, you can imagine that interpreting opinion polls and their possible significance takes an advanced degree in math and statistics.
I understand most Australians pick up a “cheat sheet” from their party of preference to copy in the voting booth. This means, that even if the Greens have no chance of taking a seat in a district, say, Bennelong where the Prime Minister is standing for re-election, their recommended preferences may make a huge difference in the ultimate winner. And there is a chance that Mr. Howard’s party might win the election while he loses his own seat in his Sydney suburb. This would catapult the unloved Peter Costello, his current Treasury Minister, into prematurely becoming the next Prime Minister. Counting the votes, all done on paper ballots, is very complex. Wikipedia has a good article on preferential voting in Australia if you are interested in the details. And, you can imagine that interpreting opinion polls and their possible significance takes an advanced degree in math and statistics.The campaign so far has been blessedly free of the 24/7 attack dog TV ads we are accustomed to in the U.S. Instead, we have had one debate between Mr. Howard, and Mr. Kevin Rudd, who is the current Opposition leader. And there are a series of sound and video bites daily, as each leader visits the marginal seats and makes the usual promises to provide education, safety and a chicken in every pot.
Each party has made some funny gaffes, most notably Tony Abbott, the mafia look-alike Liberal Health Minister browbeating his female Opposition counterpart, being rude and labelling her statements as “bullshit”. And Labour’s Environmental Shadow Minister, former rocker Peter Garrett, was caught on camera joking that if his party won the election they “would just change everything [they’d promised] anyway”.
Each party has made some funny gaffes, most notably Tony Abbott, the mafia look-alike Liberal Health Minister browbeating his female Opposition counterpart, being rude and labelling her statements as “bullshit”. And Labour’s Environmental Shadow Minister, former rocker Peter Garrett, was caught on camera joking that if his party won the election they “would just change everything [they’d promised] anyway”.
Both parties have promised to pursue some sort of rapprochement with the Aboriginal and Torres Strait Islander peoples, although what, how and when remains well undefined. The Liberal PM clearly has no intention of saying “Sorry” to the Indigenous people, believing that would open a can of worms: i.e. the government might then have to actually do something to redress the situation. Mr. Rudd is more cagey, saying that his new government would take more responsibility, but not really spelling it out much either. And both Federal politicians have made moves and threats to take over the hospital systems currently run by the States, again with no firm long-term commitments spelled out.
It will be fun to see what happens. The election is 2 weeks before we leave the country, and currently it’s too close to call. My Australian co-workers are mostly very apathetic about it. There is a widespread belief that it doesn’t much matter which party wins as it will make little long-term difference. That sentiment is certainly a very familiar one that needs no cross-cultural explanation.
