We Never Stop Learning

(from Eric)

Roughly thirteen years ago this month, Rachel and Maggie and I visited Burundi for the first time. This was the first trip of our team to Burundi and the one that led to all the others, I guess. We were welcomed generously by the leadership of Hope Africa University. We spent five days in country, mostly in Bujumbura, only visiting Kibuye for a half-day.  We learned about the country and the work of HAU, in particular their medical school which was seeking faculty members like ourselves.

Walking around the main campus of HAU in Bujumbura, I ducked into a classroom, and I looked at the blackboard. Though I didn't speak French and didn't know then (as I do know) what the French acronym "OAP" meant, I caught a few words:

Bleomycin. Cardiopathy. Swan-Ganz catheter.

Why snap this photo? Well, without going into the medical details, I was both astonished and amused that in the middle of Bujumbura, on an old blackboard, students were being taught about relatively obscure treatments and invasive techniques that I was pretty such weren't available anywhere in the country. And years later, I can say that I was right: they're not available and possibly never were.

After years of medical school and residency in the US, and with about a year of African medicine (in Kenya) under my belt at that time, I had learned so much. We were looking forward to working in African medical education, and this blackboard struck me as the epitome of what we were going to better. We weren't going to teach archaic and inapplicable ideas to our students. We could do so much more.

***

Over the years, I have been surprised again and again by things I didn't understand. I remember the day years ago in the NICU at Kibuye when I realized that no one had any idea how to use the scale to weigh the babies. Weight gain in premature babies is truly a vital sign, fundamental to guiding what the doctor should do for the baby. I saw them randomly moving the weights of the balance around, and thought "what have I been doing for the past month?" (Obviously, the NICU has developed by leaps and bounds in the many years since I rounded there.)

Just yesterday, I was working on a small hospital project with some personnel and was again bowled over by my misplaced assumptions. In this case, I thought a certain person would certainly understand some particularly fundamental medical concepts. Nope. So I walked up and met with him for a while, trying to find out exactly where he was at, because it certainly wasn't what I had thought.

Fourteen years after moving to Africa, and I keep getting surprised at what I mis-guess or misunderstand. Each time, I learn a little more, but there is always something else that pulls the rug out from under me. Something else that I didn't understand and therefore I wasn't really engaging the situation correctly.

***

Today, I walked home from the hospital after some late afternoon teaching to our post-graduate interns on bleeding disorders. It had been fun. A new challenge to try and discuss a relatively complicated subject in an effective way, somehow reaching out across the void between me and them to connect.

I thought back to the Swan-Ganz catheter blackboard of 2010. Even now, I don't want to teach like that. I still believe we can do much, much better. But thirteen years later, I would say that sometimes there are reasons to teach things that are beyond the technology available around us. Sometimes students want to know, or maybe it's coming soon. Sometimes I find that a certain point may not be clinically relevant to them, but it can help illustrate a physiology concept in a useful way, so I try to use it to a different end. In other words, I think my approach to this question is more nuanced now.

I'm tempted to look back at my "one-year-in-African-medicine" self in 2010 and think that I didn't know anything then. But that's actually quite unfair. After years of training to become a physician attending, and a year in Kenya, I actually knew a lot. I had learned and learned and had my paradigms upturned and readjusted again and again. 

It's just that I didn't realize how many more times I would keep learning. I didn't know how beyond one mountain there would always be another mountain. How I would just continue to be surprised and made to feel like I was back in month one over and over again.

It would be folly not to take this recollection and flip it forward. I suppose I will continue to be surprised. I wonder what I will know in five years that I understand more incompletely now. I think I can legitimately say that I've learned a lot, about medicine, about a totally different environment, about how to go about effecting needed change. But I'm also learning just how much more I have to learn.

***

PS. on a somewhat related note, Glory Guy's father Bobby has a healthcare business podcast and interviewed me over the summer. Click here for about 15 minutes of us chatting about how experiences here have shaped my lens on healthcare.

Taken Away My Shame

by Rachel 

Every Monday I have OB-GYN clinic at the hospital. It usually runs from 9a-5p and I see sometimes over 40 patients. The pathology is variable, but the type of women that come to see me is also quite variable. Sometimes it’s a little hunched over old widow, wearing no shoes and a dirty wrap, coming to see me for her uterine prolapse. Sometimes it’s a fancy looking woman with well done hair and perfume, accompanied by her husband holding car keys and a giant stack of medical tests, seeking help for infertility. I see farmers and teachers, nurses and business women. They come from Kibuye, Gitega, Bujumbura, and even sometimes Tanzania. Young and old, rich and poor. All seeking the hope of healing in some way or another. That last piece can be hard to remember in the crush of the day, with a long line of patients and a large stack of charts waiting. Trying to get through the day, skipping lunch, going as quickly as I can...but trying to remember the humanity of each person and their own brokenness in some form or fashion. That they need hope. 

One such patient came to see me about nine months ago. She was actually a nurse, a maternity nurse no less, at a different hospital. Her first pregnancy had ended in disaster: she went into labor at term with a healthy baby but her baby's heartbeat had started to look distressed. They performed a C/S for her, but her baby died just after birth. This is sadly not an uncommon scenario, but for it to happen to someone whose profession is to deliver healthy babies...a double blow. There is a falsehood that I probably subscribe to at some level as well, that a better job or more financial resources somehow guarantees a certain outcome in health and in life. This is not always true. 

Well, she was pregnant again, now just 5 months after her first loss. I placed the ultrasound on her belly and we were both surprised to see not one but two heartbeats: twins. This is usually joyful news, but does cause a bit more apprehension for the obstetrician! Her risk of another loss due to miscarriage or fetal death was somewhat higher, so we made plans to follow the pregnancy more closely, having her come back for follow-up visits every 4-6 weeks. And I can say that the rest of the pregnancy was wholly unremarkable. I wasn't even the one to follow her for the most part, my generalist colleagues being fully capable to perform her ultrasounds and follow the babies' growth. Her C/S was scheduled at 37 weeks' gestation. I don't even do very many C/S any more, because there are so many well trained doctors working at Kibuye these days, but that morning I happened to walk into the OR before the day had even started, and she was already on the OR table, prepped and ready to go. So I scrubbed in, said a prayer, and began the surgery. 

First, a girl. I held her up over the drape for the mom to see her and announced, "Bukuru!" The traditional Kirundi name of an older twin. The baby girl screamed her lungs out, and the mom began sobbing. Then, a boy. "Butoyi!" The younger twin. I likewise help him over the drape and the mom sobbed harder. It was, like the pregnancy, an unremarkable C/S. But as I closed up the layers and dressed her incision, a song that we sometimes sing in church came to my mind. "My beautifier, you've taken away my shame, you've taken away my pain. You've made my life so beautiful." And I couldn't help but think about how this pregnancy HAD taken away shame for my patient. Shame of feeling like she had done something wrong, that despite her profession she couldn't save her first baby. Cultural shame of not yet being a mother. These two babies HAD taken away the pain of childlessness and the loss of her first baby. Maybe not completely, as cases like this are intense joy mixed with intense pain, but healing has begun. The loss of her first baby will always linger, but redemption is now happening. Life is being made more beautiful for the loss and the pain and the joy and the new life. And I'm glad that God allowed me to be a part of it.