25 February 2011

…And back to the original precept of “medicine: the microcosm.”

The Middle East is exploding – maybe to long-term good, at least in the countries with more peaceful revolutions. Vocalizing freedom, enacting change, moving toward a more internally-designed governing system. Hopefully. Then there’s Libya… it’s still hard to have personal, visceral reactions to things when announced in numbers and not names. If one of them was my patient. If one of my patients had family there.
But as much as I – when I remember – try to remain engaged with the world in, at least, a passive way, I have no idea what’s going on.

How do I know that California (one part of the country not ever really in winter?) is expecting snow tomorrow, for the first time in 30ish years? Patients. Same way I knew it was going to be in the 60s last weekend – a patient was preparing for a trip to New York.
I don’t generally talk politics in clinic…except over health insurance sometimes when I can’t help my angry outbursts at what I can’t provide. So I don’t know as much about that. In Cameroon, I learned more about European politics than even BBC World News told me – my friends in village knew. They discussed ministers I hadn’t heard of.

And I was listening to BBC, at least, on the bus to clinic in the mornings, until I discovered itunes had free pediatrics podcasts. If I can count the morning commute as studying time, there’s less to do later. Theoretically. Or sleep. Or music I’m not even listening to. Those are the ways of dissociating from the world.
I remember the proximity of holidays from storefronts and clinic waiting rooms. Nursing staff scrubs, that’s actually another way, sometimes. Spending days in the ER, you never see light unless you’re standing by the ambulance bay or going to the roof to accept transport from a helicopter. At the end of 8 or 12 hours, you walk outside and are surprised… either that it’s night or that it’s day. Whichever. Maybe in that fast-paced environment of immediacy, current events would be more on the tongue, as everything is constantly changing and you’re not getting into longer-term conversations or relationships with people there. Then again, you’re always focusing on checklists, gestalt presentation, and minutiae of learned instinct to tell you which patient is going to decompensate quickly, and which one is not. Patient by patient by patient, minute by minute by minute. If it’s not public health, there’s not a larger picture, and if it’s emergent treat-‘em-and-street-‘em care, all you might have fixed is the very short-term problem. If that. Clinical medicine is still about bandaids, though some of them are large enough and strong enough to keep a heart or a brain together for five, ten years. One person’s heart, one person’s brain. And there’s nothing negligible about that. In most offices and hospital floors, going room to room to room, you do get glimpses of outside. It’s mobile. During things like the World Cup (I haven’t yet been in a hospital during elections), clinical staff will pause just a bit longer in doorways, or as long as possible. Patients have TVs on. On the wards, I would sometimes learn larger bits of news from patients, either that they told me or that I saw on the TV as I sat down to chat for awhile. I can’t be the only one who garners bits of the world in this way. These days. 

Clinical medicine without public health, without any focus on larger outreach (national or international), is like a room with a skylight (lets light in, does something luminous) but without a window you can see out or in. In the ER (or spending all day, every day in a surgical suite), you’re so internally focused for 12-30 hours at a time that you have no physical connection beyond the walls. 
I can’t choose a career without windows.


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