Monday, February 16, 2009

Honora continues to inspire

What is it about Honora Englander's plain-spoken dispatches from Uganda that make me smile and feel good about the future of medicine? I hope you feel the same way. Here's an excerpt from her latest:

The time here is flying by; my days are full and each day holds something new and unexpected. Some days I am wakened as early as 5:30 am by trucks barreling by my window or by the howling choir of neighborhood dogs. At 6:00 I can hear the beautiful morning prayer from a nearby mosque, and this is followed by the birds' dawn. I've been rounding on the wards with residents and students from 9 until about 1:00 or 2:00, and then teaching in the afternoons for several hours. Monday was diabetes and chest x-rays, Tuesday physical diagnosis rounds, and today was a marathon lecture on EKGs. The students are bright, well read, caring, and very eager.

Though likely of less interest for those not in medicine, I suspect that many of you will find some of the patient stories and diseases we see here fascinating. In the first bed on the left is a 31-year-old man with newly diagnosed HIV/tuberculosis co-infection who presented with cough and weight loss, and developed seizures on his first hospital day. He stopped seizing after benzos and a dilantin load, but we've been unable to establish a clear diagnosis due to his reluctance to have a repeat lumbar puncture (the first was lost after being sent for India Ink which was negative). A chest x-ray showed miliary TB and is gradually improving on empiric therapy for TB and bacterial meningitis. His mother and father tend to him daily, and their faces appear increasingly relieved as the memory of his seizures fade and he gains a small amount of strength.

In the next bed is a 66-year-old man with refractory hypertension, anemia, melena, and a pleuropericardial friction rub of unclear etiology. He speaks English well, which is a luxury for me, as so much history is lost using students as translators. Many students are from the region and thus speak the local language, but many come from other parts of the country and their comfort in Riankole is variable.

In the next bed is a 14-year-old boy who presented with lightheadedness and gum bleeding several weeks after a dental extraction, and is found to have a WBC of 1.1, Hemoglobin of 2.7 and platelets of 8. His spleen is enlarged (grade III) but other than a slight S3 and looking young and frightened, his physical exam is unremarkable. We are ruling him out for infection (TB, brucella, typhoid, severe malaria) but are all concerned about a likely lymphoma. In the meantime we are treating with antibiotics, antimalarials, packed red cells and vitamin K, and today there was a suggestion that we get platelets from Kampala while we wait for a bone marrow biopsy.

Next to him lies a young man who was transferred from the psychiatry ward where he was said to have had a psychotic episode after newly learning is his HIV positive, however his clinical course and exam suggest a chronic meningitis, and thus he was transferred to our ward. In the bed next to him is a charming 84-year-old man who was admitted with dysphagia. There was talk of endoscopy but the cost is prohibitive, so instead we are waiting for his son to arrive from the village with money so that he can get a much more affordable barium swallow. In the mean time he is cared for by a wife and young daughter who can't be more than 10 years old. Their dress suggests that they are Muslim, and each time I see his daughter in the halls she smiles shyly and then kneels.

While there are few specialists, the team of physicians here is a tremendous resource. Some days I round with a Ugandan attending, but often I am alone with my team of a first year resident and the students. The providers that I lean on most are a mix of Ugandans (mostly PGs - i.e., residents) as well as the exceptional group of European and American doctors who are here. The extent of disease, decisions around testing in the face of limited resources, and the social and cultural aspects of care are both challenging and fascinating.

My evenings are often quiet and provide down time to relax, have a leisurely dinner, read, or turn in early. Tonight on my evening run I smiled as I was passed by four waving, knee-high children in school uniforms who were crammed on the back of a boda-boda (motorcycle), and I was struck by the mix of new and old traditions that coexist here. I passed a 2-inch wide ribbon of ants crossing the road and cows grazing in the pasture. Just adjacent was the golf course where a group of Ugandan men were teeing off and barefoot children played soccer with a ratty deflated ball. A woman sped by talking on her cell phone, and just minutes later I watched a woman who was learning to drive harmlessly careen off a gravel road into some hedges (hitting the accelerator instead of the brake!)

It is near 9:30 now and I'm ready to turn in.


Lachlan Forrow, MD, FACP said...

Thanks, Paul. I love reading about the evolving career paths of our Schweitzer "Fellows for Life." Honora became a Schweitzer Fellow when she was a medical student at U.Mass., working as a 2001-02 Boston-area Schweitzer Fellow at the Epworth Free Clinic in Worcester, caring for individuals from all over the world who had arrived in the U.S. and had no health care insurance, much less a regular doctor. She's now one of nearly 2,000 medical, nursing, public health, social work, and other members of the rapidly-growing "Schweitzer Fellows for Life" network. (We're about to pick our 2009-2010 cohort of new Schweitzer Fellows, nearly 250 strong, from ~100 health-related professional schools across the U.S.)

While I and others in The Albert Schweitzer Fellowship would love to take credit for what our Schweitzer Fellows do, the truth is that we have studied pretty rigorously the impact of the program on its participants, and the idealism and passion for service is already there when they apply. We don't increase that, though perhaps we keep it from fading the way it too often seems to during people's training. All we really do is create an organization and structure within which people like Honora can find tangible ways to act on that idealism, build their skills in service that is truly effective, and feel encouraged and supported in doing so. In the process, they not only make a real difference in the unmet health-related needs of their neighbors, whether here at home or thousands of miles away in places like Uganda, they also often find a depth of personal satisfaction and meaning that is hard to top. Finally, in the Schweitzer spirit of "Example is not the main thing in influencing others, it is the _only_ thing", they then inspire others, as Honora is obviously doing, including Paul and me.

I think that there are some pretty direct implications of this for any health care organization in the U.S. The greatest asset any organization has is the morale of the people who work there, and being supported in doing work one is truly proud of is energizing, infectiously so. The converse is also true -- clinicians who feel frustrated in their efforts to do work they are proud of feel literally de-moral-ized, and there is growing evidence that this is a major problem for staff recruitment and retention. So even the most hard-nosed, bottom-line-oriented business person should care.


Lachlan Forrow, MD
Director, Ethics Programs

PS: Disclaimer [or expression of pride? or both?]: BIDMC is the home of The Albert Schweitzer Fellowship; I am the President, and Paul is a Board member -- see ...

Anonymous said...

Nice article.

Bilety lotnicze said...

Honora Englander is an inspiration. Shes done a lot of good. God bless her.

wakacje said...

Very Nice article, thanks!