A week ago Friday I visited Kanye as per usual. I had a feeling the presentation for that day would be met with a lively discussion as the staff there is both bright and a not a little outspoken. Since the topic was delirium I knew that this would make for a lively conversation. At the end of the case presentation I asked if anyone had any questions or comments. And did things ever take off.
I always subscribe to the notion that there is generally more than one right way to do something in a medical context; from diagnosis to treatment the circumstances are so variable that it lends itself to anecdote over evidence. There were three excellent physicians from Nigeria in the room. One was clinic based, the other two were on the hospital staff. One offered up and idea that was a touch off the beaten therapeutic path and I offered that it might be a better idea to do "X". The outpatient doc scoffed and said how it was so obvious that what I said "was true" ,that only a bonehead would miss that. And while he was on the subject, and had a full head of steam, he began to comment on the difficulty he has/had in routine referrals. "Oh yeah, well how about the stupid referrals you send us without even a referral note or phone call?"
This was great, I smugly told myself. Before I came the two separate staffs were not interacting like this and feelings were scorched or ignored out loud. But things went south from there; to football, to "exactly where in Nigeria are you from and what medical school did you attend", to loudly discussing who was going to win the World Cup. I got a little uncomfortable and tried to intervene such that things would at least get back to medicine. Yeah, right.
Things became even louder. I raised my voice in best impatient father/attending posture and attempted to gain control. Nope, wudn't gonna happen. Finally one of the guys stopped and laughed, confessing that "Nigerians love to argue" and "never get two of us in the same room and bring up football, women, or medicine" Got it.
100% of the women on the wards that day had HIV. The concurrent and co-morbid diseases that these heroic women had were of course devastating. Yet their quiet stoicism was remarkable. Usually it's the women that make an outpatient environment so difficult as there is so much somatization and outright malingering. Without exaggeration they might have six different pains for which they want/demand "treatment". And if it is denied, rather than face the embarrassment of their peers out in the queue who did get treatment (read "tylenol") they yell to us "you want me to die!" We of course gently deny this and things often spiral down from there. Ask any outpatient doc how many of their patients truly don't or didn't need to be seen on any given day and it will be in excess of 70%. This dates back to the 40's through the early 60's when Western style doctors/evangelists came here with two agendas; treat and/or recruit. On the treatment side one of the secondary agendas was to evangelize so the path of least resistance became "treatment". And here we are.
Long time residents will say that this mind set of treatment for anything at any time pre-existed the missionary movement. And perhaps it did. What they did here was heroic in its own right. But not without consequence and the "you want me to die" paradigm might be one of them. Buy I digress...
When someone here is truly sick, one of the most telling signs is that they are very quiet, stoic, and patient. The biggest challenge is to pick them out of the queue such that they are seen more expeditiously and "treatment" is administered. As I've seen all over the world, it's the entitled ones that are the least sick but might be the most worried. The quiet ones are the most sick and might be the most entitled.
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