Wednesday, June 23, 2010

Not Medicine, But Life

Well, it seems no one read (or cared) about my inner issues from my last post. That's fine, not like I expected anyone to care about my ranting and whining. Kind of like I wasn't invited to a friend's wedding, even though I've known him for 4 years in undergrad. Granted we weren't really close friends, but we hung out and chatted and all that. My best friend from undergrad (his best friend) was really mad that I wasn't invited - but such is the story of my life.
Anyway the purpose of this post is to update you all on my last week and a half of my externship. What I saw was surprisingly little medicine, and a lot of life's psychosocial issues. What I saw were mostly "special populations."

Pediatric HIV patient
Last Monday I observed a patient in Dr. H's pediatric HIV clinic. The patient had contracted HIV via mother-to-child and was slowly being transitioned to adult HIV care (being 24-years-old already). I was in there with Dr. H and 2 of his HIV nurses. It was clear that Dr. H had known the patient for many years - 10 years at least I think.

Of the 1-hour or so visit, surprisingly little time was devoted to HIV care. Most of the time went towards helping the patient resolve personal issues - with her relatives, with getting a job, with her boyfriend, etc. She broke down more than once and cried on Dr. H's shoulder. All this was necessary such that she'll be able to get herself out of a rut and take her meds regularly again.

The following morning, Dr. H left me with some words of wisdom:
When a doctor or a student says, "The patient won't take his/her meds," change "won't" to "can't" in your mind. Think, "The patient can't take his/her meds."
Powerful words indeed. I could go into a whole post on those words and what he asked me to look up after the clinic visit, but I may save that for some other time.

Children's Court
Last Wednesday I went to Children's Court with several other externs. A retired judge met us there and gave us an introduction to Children's Court and what they did. They handle cases such as: juvenile delinquency, child physical abuse, child sexual abuse, negligence, etc. Their "goal" is to eventually reunite parent and child, even if the parent is . . . less than perfect. Usually - and curiously - the alternative (foster care) tends to be much worse for the kids.

I'm glad I was able to get an opportunity to sit in on a few hearings, though the presiding judge seemed rather annoyed at our mere presence in the courtroom. It's an opportunity not many get (at least, not in such a manner). It really is kind of like how it is on TV, lol. As such, I'm really glad I didn't go into law - the procedural stuff isn't for me.

International Adoption Children
Last Friday I accompanied the head of the pediatric infectious disease department (Dr. C) to an international adoption clinic. He had me read 6 chapters of a book the night before (which took me forever to get through - all but one of the assigned chapters was about infectious diseases). The 2 clinic visits were . . . interesting.

The first clinic visit went pretty smoothly. The adopted baby was quite cute and playful, and seemed to be adjusting alright. Dr. C did seem a bit concerned by the kid's "hyper-geniality," that is, he's too friendly with strangers. In the reading he assigned me, this could indicate lack of attachment to caregivers, which is a problem as kids can wander off with strangers too easily. The child psychologist agreed that it was something worth watching.

The second visit was kind of bizarre. The 5-year-old kid was adopted from Hong Kong and knew very little English. An interpreter was called in (alas, I can only understand but not speak Cantonese). The kid had so many issues, mostly behavioral. The parents seemed at wit's end at times during the 1-hour visit. On the way back to the hospital, Dr. C told me that, while most parents probably mean well, they don't fully think things through when they adopt international kids. Often times these kids are "damaged" in some way - either inherently or as a result of institutionalization (orphanage, foster care, etc). Dr. C only saw disaster for this family in the future.

Inner City Kids
This week I began working on my primary care pediatric mini-rotation . . . in the inner city. I get this feeling that all of us externs are to do our primary care bit in the inner city. While the last primary care pediatrician I shadowed was in the suburbs (where almost all his patients were white), this time I'm in the inner city where almost all the patients are black. And also, a lot of the patients are younger in age - so I saw a lot of babies.

I mean, today most of the patients were 1-month-old babies. One of the dads yesterday looked at me and said, "You don't have a kid, do you? You have that look on your face." I asked a lot of dumb questions about babies because, again, I know nothing. It's nice to know that the medicine we're taught has such an emphasis on adult care that pediatrics often get shuffled to the side (or at least that's how it feels to me). ::Insert sarcasm::

At the end of the day yesterday (the pediatrician I'm working with now works 8am to 8pm on Mondays, Tuesdays, and Wednesdays), he held up 5 billing sheets and told me: "See these? These amount to about $600 because all these patients are Medicare. If they all had private insurance, it'd be closer to $2000." What's frustrating (to the pediatrician and me) is that in primary care, we have to treat the patient population as richer and poorer. And that dichotomy greatly affects care no matter how neutral doctors try to be.

He also told me that where he did his residency (in Illinois somewhere, I forget), the hospital system was in a bit of financial trouble and needed more revenue for whatever reason. So the hospital implemented a program to increase the number of circumcisions they did because each one brings in hundreds of dollars, it's relatively easy to do, and it's billed more because it's an elective procedure (that is, it's not necessary to one's well-being). And it's totally unethical - we were both in agreement on this point. It's almost like trying to promote appendectomies on healthy individuals. It infuriates me to think about it more. Note to self: avoid that residency program.

For health care consumers, I suppose you should be careful if a doctor or nurse pushes too strongly towards a surgical procedure when none is needed or when alternatives haven't been considered - there may be something more behind that than "good medicine."


dursus said...

Hey, Aek! I recently started reading your blog and I love it because I can associate with your struggles. Please don't think that no one reads or cares about your posts. I don't comment as much as I read, so just want to let you know that your blog and your posts are much appreciated.

Mike said...

You bring up a great point about children from international adoptions being damaged. All those Russian kids in the news now, and I have a few anecdotal stories about Russian kids. But then there's Angelina who seems to be saving everyone and doing a bang up job. We haven't heard about them having any issues.

The innercity kids part was interesting too about the hospitals/money/billing.

Biki said...

wow! Who knew that doctors pushed procedures only to make money? How completely unethical of them!

I'm sorry for my lack of comments of late, will try to do better in the future.

And yes, most of the people I know that have adopted international children have had many issues with them. All of them emotional, and some physical. Which has led to many heart breaks and tears, on both sides.

As usual, a wonderful thought provoking post, thank you.

tracy said...

Excellent, touching post, Aek.

i usually don't know what to say in response because i am so impressed with your writing ability and i have none.

Just, thank you, so very much for this, another fascinating look into the world of a Medical Student...i loved it.

Earl Grey said...

OOps, sorry i've been awol on reading (and writing :P) forgive me?

The HIV situation is one which is really very upsetting, but I think it really goes to show how care is more than just a matter of taking pills or in some cases eating and sleeping right.

good on you and keep up the good work!

Anonymous said...

hey even though I'm not being as generous with the comments I am still following along with rapt enthusiasm as I get my medical-degree-by-proxy through your experience

fwiw - my neighbors adopted a 3 year old boy from Ukraine about a year ago - we joke that they went out and bought their daughter a baby brother but sometimes it seems that way - he is a wonderful and happy kid but definitely a little too friendly with strangers - maybe not a bad thing once he gets older but a bit scary at this age