Fulfillment, self - actualisation, feeling worthwhile. Are these things more important for doctors than for other people? Probably not - but certainly during our long medical training we long to stop being spectators, and to do something useful. We want to help - and if that help is appreciated that is also nice.
But then we can often find that many aspects of our work fail to live up to our expectations. There are many patients whose degenerative disease we can do very little for. There are probably even more patients who come to see us with symptoms that have more to do with their psyche and their place in society than with classical diseases, and whom we are also poorly placed to help. We also become painfully aware of all the patients whose problems are actually caused by medical treatment in the form of harmful drugs, harmful medical tests and failed operations. We know that our efforts in preventative care with respect to diabetes, blood pressure, cholesterol, cervical smears etc. only help a small minority of patients. Even when we do the right and helpful thing for example stitching up the head wound of a drunk - he expresses no gratitude, and we can get a bit fed up with the likelihood that he will be back soon with the same problem.
So perhaps the answer is to go and work somewhere like Africa where one can prevent needless deaths and suffering by diagnosing and correctly treating curable diseases such as infections which might otherwise have gone untreated. The patient says thankyou and comes back and is better - and a warm glow spreads around.
That scenario does actually occur - sort of. It is common for patients to come into the clinic complaining of ‘malungu’ (malaria) which consists of ‘mbepo’ chills, ‘kupyay’ fever, and ‘muto’ headache. I do the rapid test for malaria and sometimes it is positive. The patient gets better quite quickly on co-artem treatment (based on artemisia a chinese herb!) What is not to like? Well, just that there is not a lot of skill or training or experience involved so one does not feel particularly useful. The clinic receptionist could maybe do it as well.
More serious harm to the self image of the hero helping his poor african brothers comes from some basically fit and well africans who have a bit of a cough and a cold. They come to the clinic for some strong Mzungu (i.e. white) drugs, and possibly a sick note, and perhaps understandably, do not sympathise with my wish to mainly see patients whose life i am going to save! Explaining to them that they will recover with no treatment does not go down that well and scores zero on the fulfillometer.
Then there is the not so rare occasion in which my skills and training and experience are simply not up to it in this environment. I am pretty baffled several times a week. Partly there are things i just am not experienced in, like HIV treatments or Sexually transmitted diseases, and partly it is things like skin rashes on black skin.
Last in the frustration game is when i know the right treatment - but we do not have it in stock at the time, or we never have it - i.e. Asthma inhalers, or decent wound dressings. Or when the patient needs to go to hospital an hour away and they have no money for the journey. A woman aged 40 or so came in today, known HIV, on ARV drugs but looking unwell, feeling weak, but with no obvious specific diagnosis. I did a referral letter and drove her back to her home about 2 miles away as she was too weak to walk back. I am hoping that she manages to borrow the money to get a lift to the hospital but I have no idea if she will be able to do that. Even if she does get to hospital it is likely I will never know what happened to her, as this usually relies on someone physically delivering a discharge letter back to the clinic - which is rare.
But there are some patients that i can help, who probably would not get that help if i was not around. A tonsillar abcess, pneumonias, ear infections, wounds that need stitching, probable stomach ulcers. And every now and then a life is saved! Yesterday a young girl of 21 came in. ‘Pregnant and dizzy‘- were the symptoms. Not obviously exciting. But then I felt her hand, which was very cold, and it became clear that she was seriously ill. She had had low abdominal pain, and was very pale with a weak pulse and a very low blood pressure. A ruptured pregnancy in the fallopian tube with internal bleeding was the obvious diagnosis. Luckily I managed to get an IV line in and gave some saline, and the relatives understood the need to get her to hospital quickly. She had a successful op at the local hospital and she is doing well.
Without my presence in Mfuwe she would certainly have died. Which I cannot often say in England!
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