Thoughts on transitioning back home

My time is swiftly coming to a close here in PNG. Already I am starting to prepare for my departure and it is predominately with sadness. Here are a few thoughts I’ve had as I wrap up my time.

As I reflect particularly upon the transition back to my work in the States it is with mixed feelings. Here in PNG the main difficulties I have had have been the want of equipment and medications and access to procedures; from desiring the proper medication for patients in the clinic (BPH meds to Lasix, which we ran out of shortly after I arrived) to the ability to obtain a CT or MRI for a patient to clarify a diagnosis to the more heart breaking need for proper respiratory and ventilator support for critically ill neonates and children. Knowing that outcomes for a patient, particularly a child, would have been different if the necessary materials were available is difficult and it is nice to be heading back to where supplies are plentiful. However, it is also with reservations that I head back. Here in PNG documentation consists of the essentials to communicate important diagnostic information and treatment plans, but does not suffer the burden of satisfying medical billers or future litigators as in the US. The main purpose is patient care with an emphasis on efficiency. I was reminded of the stark difference reading through emails from home with numerous attached documents of the particular documentation requirements of a specific population with government insurance. I do not doubt that EMRs and the current documentation requirements have helped to provide more comprehensive care, however, I believe they also contribute significantly to burnout and decreased time in direct patient care.

I have had numerous discussions with the missionary physicians here about the differences in practice here and in the States. In the US, we frequently discuss whether or not a test will inform our treatment decisions in an effort to minimize unnecessary testing. Here it is taken to a whole new level. I had thought I was thinking carefully through tests before, but here there have been numerous times I have suggested ordering something only to be challenged on whether or not that will meaningfully change my plan of care. Over the course of my time, I have learned to rely more on clinical exam, nursing reports and typical disease course than on laboratory values or imaging. Although there is theoretically universal health care here, the only way for hospitals to make ends meet is to charge patients or receive donations or both. Tests here cost money for the patients (often between $1-5), which, for many of our patients, is a significant investment. Minimizing unnecessary tests has very practical implications for our patient’s lives and makes it that much more critical. It is frustrating that this has to be true as I wonder if care were truly free if we would see patients come in earlier and thus be more likely to respond favorably to treatment. Of course it’s impossible to know for sure.

Over the course of the month, I have been thinking about a quote I stumbled upon a few weeks before departing for PNG: “Tact, sympathy, and understanding are expected of the physician, for the patient is no mere collection of symptoms, signs, disordered functions, damaged organs, and disturbed emotions. He is human, fearful, and hopeful, seeking relief, help, and reassurance. To the physician, as to the anthropologist, nothing human is strange or repulsive. The misanthrope may become a smart diagnostician of organic disease, but he can scarcely hope to succeed as a physician. The true physician has a Shakespearean breadth of interest in the wise and the foolish, the proud and the humble, the stoic hero and the whining rogue. He cares for people.” The last paragraph from Harrison’s Introduction, First Edition, Harrison’s Principles of Internal Medicine, 1950. In some ways, by removing the bureaucratic work and computers, PNG has helped me to come back to being able to see more clearly the humanity of my patients. In others, it has offered new obstacles of language and culture. I took one morning last week to do rounds with the chaplain through the Medicine Ward, which I had been working on for almost a week. By getting the chance to sit down with, listen to and pray for some of the patients, I learned a lot more about some of my patients than I had discovered on morning rounds. One of the women who had been admitted for a suicide attempt with gramoxone ingestion (a type of herbicide used frequently here as a means of suicide) informed us that she was pregnant, something that she had hitherto not shared. Another woman with undiagnosed abdominal pain told us about her unfaithful husband, her family’s refusal to let her divorce and her fear of contracting AIDs. I hope in the future, whether here or in the US or somewhere else, that I will not let the numerous obstacles that will always be present interfere with my ability to truly see, listen to and care for my patients.