Afghanistan

 The fall of Kabul reminded me of strange, long forgotten things.

When I was a child in Calcutta, going to school in a school bus and noticing everything around me. I remember huge men in pastel colored salwar kameezes, bearded and so much taller than local folks in West Bengal. They were known as Kabuliwallahs who brought dried fruits from Afghanistan and someone told me that they would usually be waiting near the factory gates to collect debts from the workers. There were at least three huge factories that I crossed on my way to school-- a cotton mill, a jute mill and a ship yard. Only the shipyard survives.

I used to accompany my grandmother to radiotherapy for her breast cancer to a radiation unit in Calcutta. I must have been eleven years old and I remember an Afghan man who may have had oral cancer and whom no one understood as he seemed to only spoke Pashto. It was heartbreaking then and even now, it strikes me as sad not to be understood. I still think about him sometimes.

One of my colleagues in residency for whom Medicine was a second career, told me that he had backpacked in Afghanistan, so very long ago. I was jealous of him as I imagine it is a beautiful country. In the few hours of history I learned in school, it was said Babar missed the gardens of Kabul, where he is now buried. The inscription on his tomb in a garden in Kabul, is said to reads "If there is paradise on earth, it is this, it is this, it is this!" For us in this millennium, we can only think of the destruction of the Bamiyan Buddha.

More recently, I was waiting for my takeout at an Indian place, another patron shared that she was stationed in Afghanistan and loved the unleavened bread from a tandoor, one of the foods she got used to during her deployment there.

For all of us, faraway places feel closer when we understand the people who live there. I saw a movie called The Breadwinner on Netflix a few years ago which told of the struggles of people living under the Taliban. It touched me deeply then and as I think about the people in Afghanistan today, I hope better days are ahead though I worry that life under the Taliban will be much, much worse.

Hiraeth

I am homesick
longing for whatever isn't
feeling lost,

and out of sync
who knows when I'll
feel found.

there isn't the peace,
or the cadence in my days,
what work I do is meaningless, anyway.

Wisconsin Wednesday

The first Wednesday of each month, around midday, the alarm system for tornadoes gets a test run. It always makes me jump out of my skin  and think about how Midwestern homes are generous with their basements and how winter leads directly to hot weather and mosquitoes and how it is either central heating or blazing air conditioning all the time.

I am selling this place short but when my neighbor mentions how beautiful it is, I feel like a scrooge. He says it is like a California day...I answer No, not really. A bit oppositionally defiant, on reflection. I could have been a bit more accepting. It is indeed a beautiful day.

Winter Storm

It is snowing today where I live and it will continue through the night. I wonder what the morning is going to be like. It is interesting to be an outsider in the Midwest. I grew up in Calcutta, India, which for better or worse, will always be my home town. Calcutta is a ragged place, an ancient city bursting at the seams sort of place with too many people who seem to be going anywhere you are headed. A noisy place where cacophony accompanies existence and where a few moments of silence and repose are precious and unlikely.

Now, I live in a quiet, too quiet- almost to the point of moribund "development" in a Midwestern suburbia, surrounded by McMansions, where I have to drive to get anywhere- although things are easily accessible but I miss walking and sunshine and fine weather without mosquitoes thrown in for good measure. I think about other immigrants to the Midwest- I know there are Hmong people nearby and lots of folks displaced from Somalia, too. I wonder how they cope with the winter mayhem.

I miss the getting outdoors without planning and being a flaneur in the sunshine. It has been horribly cold recently- like breaking decades worth of weather firsts- cold. So venturing out those days was impossible. Warmed up for a bit with some sunshine thrown in for good measure and then it froze. Every walk I have taken has been accompanied by the nagging thought that I should have worn my yak trax for better traction on this frozen slippery tundra. And yet, the whole act of have two sets of shoes- one for the outside and another for being indoors hasn't got any traction from me. The winter gear is beginning to wear me down. It has always been so. February is a tough month with little sunshine, dreary weather and a sense of cabin fever. I wonder if I will every adapt to this weather. I know human beings are resilient but right now I would like to be anywhere but here. 

The Problem of Expertise

Recent conversations have reminded me about an experience I had with an Oncologist whose patient I was helping to care for in the hospital. He wasn’t doing too well. He looked terrible and his laboratory tests reminded me of his poor health.

I came across his cancer doctor in the hospital corridor and we talked a bit about his diseases and management. I shared that he wasn’t looking well. This lead to a shocking, memorable response that still rings in my ears.

“Whatever it is- it isn’t his cancer that is killing him.”

Even today as I write this I am shocked at the slicing and dicing that goes on in the corridors and clinics of the hospital. All of us can be imagined as a system where many different organ systems have to work well on their own and together for us to feel healthy.

As a generalist in the hospital, I take care of a wide variety patients and this is a recurring theme in my interactions with specialists. Usually, when there is diagnostic dilemma or therapeutic conundrum rather than approaching the problem with a wide lens and humility- there is sometimes the implication that I have taken care of “my organ system”; now if things aren’t going according to plan then the problem lies in another organ system and so we need another consultant.

This begins what I call a consult-a-palooza. One consultant asking for another consultation and before we know it contradictory recommendations start flowing down the pipeline. Usually, this doesn’t lead to the best patient outcomes.

Common example of this being someone in Renal Failure and Heart Failure where the Cardiologist will recommend a diuretic drip while another consultant may recommend holding diuretics. It can be quite challenging to reconcile these opposite therapies unless the Hospital Medicine doctor has a viewpoint and can explain their perspective logically.

In these days when collegiality is uncommon, it becomes difficult to reconcile opposing therapies especially when they are recommended for the same patient. It can be impossible to reconcile recommendations for complicated patients with multiple diagnoses and comorbidities.

Part of me really enjoys this puzzle solving aspect of Medicine and part of me gets quite frustrated by the communication problems, therapeutic delays and human suffering that come along with every patient that is a diagnostic and therapeutic conundrum.

Sometimes, these occurrences feel like Medicine’s version of “Not my problem”. Well, ultimately it affects the patient so it is everybody’s problem and one that we cannot slice and dice our way out of. Expertise is supposed to help get the best care for our patient and not shrug off a problem.

I always feel that this sort of thing ought to be the special strength of an Internist and we ought to rise to the challenge of being able to diagnose and care for the medically complicated patient and never offer the cop out of: “this isn’t my problem”. I hope generalism continues to rise to the challenge of the “complicated patient” for whatever reason that they happen to be complicated.

A Good Day

1. Wake up rested on one's own.
2. The coffee is smashing,
3. And the biscotti crisp.
4. There is time to do yoga.
5. Nothing awful has happened in the world, yet.
6. There is no argument before school and work.
7. The commute is calm with music one loves.
8. The work day goes smooth with just enough challenge.
9. Dinner is tasty and nutritious, too.
10. The day is done with some lines written and read before bed.

No Respect for the Generalist

One of the parts of my job is holding the triage phone. This is not something I enjoy. It feels like folks call me for a way to reach other folks and finagle transfers to our teaching hospital. I am not at my best on the phone and phone tag is irritating.

My first conversation with the outside hospital doctor started with bare bones introductions before she asked me if I was a nephrologist because she wanted an expert opinion on whether her patient needed hemodialysis. Now, this was a woman with lots of comorbidities who had heart failure which was responding well to diuretics but her creatinine has creeped  up. We discussed her care and decided that there was no indication for urgent hemodialysis.

My very next call from another outside hospital was for another person with newly diagnosed congestive heart failure with a prior history of chronic lymphocytic leukemia. Now, here even before our introductions, the doctor blurted out, asking me if I was an oncologist. I told him that I was a primary care doctor working in the hospital. We reviewed the details of the patient's history and concluded that he needed management of his shortness of breath before looking at further oncologic management.

It is shocking to me that generalists don't seem to trust their own clinical judgement. Care for a patient often degenerates into a consult-a-palooza where a lot of specialists opine about diagnosis and therapy without a leader of care so that therapy may not always be in the best interest of the patient. This is a common scenario which plays out daily in our hospitals and reflects poorly on our internists.