Challenges becoming more evident in medical arena

12/31
- Today, our work brought us to Baranagar, also in North Kolkata. We started work as soon as we got there at 2. The room today was much more well ventilated and larger than the room at our last medical camp. It is going to be a new schoolhouse for the children of workers at the jute mill. This time, each person had a slip so we did not have to do any pre registration. This environment proved to be much more challenging with lack of translators, but Sandeep and I were managing as the two other stations were held up by Kal and Turja, respectively. Community leaders were so eager to help us in any way they could. One local around our age (wearing a ManU jersey) had a certain way with the elder patients as he was directing them to the different stations. Today, doctors were not next to us but at a central table. I think that worked well in terms of efficiency, but they spent even less time per patient- about 30 seconds per, glancing over the chart, and prescribing something. Certainly many of these malnourished needed the vitamins (especially B and Calcium) and many suffering from pain could certainly use the paracetemol. But I could not help but think that the doctors were using our supply of medicines as a way of circumventing a full diagnosis. Could I blame them? Probably not. The doctor patient relationship was basically non existent and I think that it was left to us medical assistants to carry this out. Because of this, today I took it upon myself to take the patient to every station, making sure that the doctor was not ignoring any of my notes or being too hasty with his prescriptions and ensuring that the patient was being instructed on their medications properly. Another side note: these patients were extremely patient with me. They let me struggle a little bit with the BP cuffs, let me struggle with my mediocre knowledge of Hindi. Had I been working like this in the US, I think I would have been promptly replaced. Here is the first ethical question: If we are not deemed certified to carry out such work in our own country, can we do so in another whose resources do not match that of our own and whose need is greater, provided we are somewhat trained? I think the answer is an overwhelming yes.
The other problem I was struggling with is how we should prioritize our long term research goals. While we are not doing any actual hard analysis on this trip, we have put ourselves in a position to do some once we return. We have copied (almost) every patient's records which contain information such as their pulse, bp, weight/height, chief complaints, and what medicines we prescribed to them. Height and Weight, used to calculate BMI, is a particularly important piece of information we hope to gather, along with the different types of illnesses/associated medicines are most prevalent. But why are we doing this? First of all, having hard data is something that prospective corporate donors and other grant providing organizations love because it provides a measure of tangible outcomes. Second, if we compile records then maybe we can better understand what the population needs most so we can direct our efforts that way, yada yada But is our work going to produce tangible outcomes in the future? After all, aren't most of the problems we are seeing a result of systemic issues such as lack of clean water and access to sufficient nutritional food sources? At this point, I see our efforts of providing much needed vitamins, and medications, as a stop-gap. While this fact is what disturbs me most, I suppose stop gaps are common in the practice of medicine and we are at least preventing continual suffering. I hope Pratit will eventually become an organization that truly is able to change lives permanently, but a lot of this depends on our funding, how much time we can all commit, and whether we adhere to long term goals that will make us sustainable. For now, I am happy with the experience I have had, but at best cautiously optimistic about what we can achieve. Going back to balancing research goals, there were times when the patient demand was so high that we simply could not jot down everything and the doctors were just telling us to forget about height/weight, bp and get down to what the person was suffering from most and prescribing necessary medications. Furthermore, we also could not ask our survey questions related to the public health situation such as what the patients thought of their water supply, how many children the women had, what problem they thought could be most improved (education, clean water, healthcare) in their slum. These are important questions but when we asked them we were spending more time per patient and risked not giving humanitarian aid to as many patients as possible. We also ran out of the pads and carbon paper was flying everywhere, so not all patient records were copied. While this is not ideal (one may even call it a shame that a handful of patient records were not recorded. I, for one, was being very anal about all of this probably at the expense of being more efficient with my patients. At one point, I was even frantically copying information from a patient’s chart that we did not have a carbon copy of). All of this brings us back to another central question, which I will borrow from my colleague Collin’s blog: When time, materials and personnel are limited and the patient demand is overwhelming, should long-term research ambitions, which hopefully will contribute to the long-term health of the community, be dismissed in favor of providing as much immediate humanitarian aid as possible? I, for one, am more sceptical about whether our research ambitions will lead to improvements in the long term health, and am a little less worried about how we balance our goals. I think we've put ourselves in a good position with our diagnostic records and research about their medical condition, but our research about their personal lives and way of living from a public health standpoint needs more work. Maybe doing a few interviews could give us a good representative idea of what needs to be improved most on a macro scale? This way, we aren’t spending time per patient…
One man, about 28 years old, Ajay Sankar came to me at the end. He was healthy (I did not see a need to weigh him especially given our time constraint. Hmm I guess I wasn’t as anal as I initially thought. Shouldn’t I have weighed him for research thoroughness?) and had a look on his face like no other patient I had seen before. I sensed he was here not because he felt he was sick- he told me he had a cough but attributed to the cold weather and clearly understood it would get better with time-but to experience our clinic for what it was. Here was a fellow who I could see had the ability to form insights unlike many of his peers, albeit with an inherently youthful, cheeky nature which resonated with me. I suppose the best word to describe him is one I will borrow from my mothertongue: “chalak” So I brought him over to Collin and I was proven right. We learned so much about the community’s history from him.
Another incident from the day that causes me much inner turmoil: There was a man suffering from asthma, whose inhaler ran out of its dosage. As part of our medication supply, we did not have any albueterol or extra inhalers. What do we do with a patient like this, whose need is not immediately met by any medications we have? The decision was made (though I was not consulted) to give him money to buy an inhaler. A community person was instructed to take him there. At first, I was annoyed when I heard this. Why should we trust them to buy medicine with the money we gave? Who is to say they won’t buy something else with that money? Shouldn’t we be the ones who go and buy the necessary medications? I still don’t know the answer. But I do know that this whole project assumes some degree of trust in the patient. We do trust the patient to take the necessary medications we prescribe them anyway. Who is to say they won’t sell those medications too? There is only so much we can do, but from a human standpoint we must assume some degree of trust.