Wednesday, January 4, 2012

It Takes a Village

     One of the most challenging parts of going through medical school was getting through the basic science, the two years of "stuff" that you have to study before moving onto your clinicals. I went to Mercer University School of Medicine in Macon, GA. From its inception in the early 80s, Mercer's medical school utilized a strictly problem-based curriculum, elements of which have now been adopted by major medical schools across the country. Instead of basic science lectures, we were assigned to organ-based tutorial groups consisting of six to eight students and one or two faculty mentors. At the beginning of each new phase, we would receive a list of recommended reading, along with several case scenarios that had been constructed specifically to stimulate a detailed discussion and understanding of core basic science concepts for the organ system we were studying, from anatomy and cell biology to pathophysiology and pharmacology. In plain English, we were not being spoon-fed the material we learned; we were expected to teach it to ourselves. This proved especially difficult for those of us who didn't have science backgrounds. I had never even heard of cell biology until I started medical school, and spent the majority of my first year feeling like I was tragically behind the eight-ball.
     Our first case was cholera, a water-borne diarrheal disease which occurs primarily in developing countries and areas with poor sanitation. The pathophysiology and cell biology involved in this case were absolutely mind-boggling to me. First of all, I never realized there were different kinds of diarrhea. Unlike that old song which we all recite with glee at some point during our childhoods: "Diarrhea, cha cha cha, diarrhea, cha cha cha, people think it's something funny, but it's really brown and runny", cholera causes a profuse, watery diarrhea which rapidly leads to life-threatening dehydration. An endotoxin (poisonous substance) from the Vibrio cholera bacteria binds to the chitin molecules in the exoskeletons (outer shells) of brackish-water crustaceans (crabs, shrimp), and once ingested, the endotoxin survives the acid environment of the stomach and enters the small intestine, where it alters sodium-chloride channels within enterocytes (intestinal cells), permitting extremely large volumes of sodium and chloride-rich fluid to be secreted, overwhelming the absorptive capacity of the large intestine. In the midst of dissecting this case, I came to the conclusion that problem-based learning was going to be a bit of a problem.
     It appeared that our first tutorial groups were split up according to segments of the alphabet. Out of a class of 56, the people in my group all had last names that started with "K", "L", or "M." I quickly became close friends with a guy named Matt Lawrence*, who had been a Peace Corps volunteer in Benin, Africa until a week or so before we started classes. I loved listening to his tales about life in the African village. Because I had previously worked in a psychiatric hospital, I was especially interested in how the village treated its mentally ill inhabitants. He described how the villagers gave Omolare*, a local schizophrenic, the job of sweeping their huts daily with a bristle broom.  Omolare was a superstitious, colorful character, who was always dancing and telling elaborate stories, replete with gesticulations and dramatic vocal inflections. He loved drinking distilled palm wine, a kind of African moonshine, and Matt had brought back several bottles of the stuff with him, which we used to pass around at parties. The bottles were filled with what looked like twigs and stones, and the liquor was thought to have magical powers. I remember thinking how progressive that village was, in contrast to how we manage the mentally ill here in our own country, and based on Matt's stories, I had a very vivid image of Omolare in my mind.
     About three weeks into our first year of medical school, Matt suddenly became extremely ill. He was sure it was malaria. The onset of his symptoms was consistent with an incubation period within the time frame of his having been in Africa, and as an international traveler, he maintained a high index of suspicion for developing signs of a tropical disease. He'd seen cases of malaria among the villagers, and was attuned to the flu-like symptoms of fatigue, sweating, jaundice, muscle aches, and loss of appetite. Depending on the type of malarial organism which invades one's red blood cells, the symptoms can be mild or severe. In severe forms, the parasite can actually disrupt the blood supply to vital organs, such as the kidneys and brain, resulting in life-threatening renal failure, seizures, and coma. Matt looked and felt  terrible. He couldn't come to class because he was so weak from fever. His red blood cells were in a continuous state of micro-explosion, causing yellow jaundice and severe anemia. His liver and spleen were enlarged, and he could hardly walk. We were all really worried, as was he because he suspected he'd been infected with Plasmodium falciparum, a parasite associated with one of the most serious forms of malaria. He wasn't strong enough to fix a sandwich for himself, and I took him a basket of home-cooked meals so he would have something quick and nutritious to eat. He'd had some bloodwork done, a peripheral smear, but the pathological diagnosis of a severe case of Plasmodium falciparum malaria can be tricky. The parasites can hide in tissue capillaries, causing a falsely low visible parasite count when the slide is examined under the microscope. Repeated smears are sometimes necessary in order to catch the parasite in its proliferative stage.
     While awaiting diagnosis, Matt sought help from Dr. Havens*, one of the infectious disease physicians who tutored our basic science groups. This guy had a serious superiority complex, which was evident from the way he shrugged off Matt's symptoms. He was convinced that Matt had somehow invented his illness, and attributed his symptoms to first year medical student hypochondriasis. He presumed that Matt was susceptible to developing faux symptoms of every disease he studied. This couldn't have been further from the truth, and Matt came pretty close to dying. Dr. Havens refused to empirically treat Matt's symptoms with anti-malarials, claiming they were "too toxic", the real reason being he simply didn't believe Matt was infected. I think Matt had go into the hospital for a few days for a fever workup and management of his dehydration. It was while he was there that a repeat smear revealed that he was infected with Plasmodium falciparum. He finally received the anti-malarials, but his recovery took several weeks. Miraculously, he managed not only to study while he was ill, but to pass his all of his exams.
     Westerners are notorious for viewing more primitive cultures with disdain: "Oh, those people are such barbarians!" We feel smug in our assessment that we're somehow more civilized because we have indoor plumbing and televisions and the internet, yet our streets are filled with homeless people, many of whom are mentally ill. We put them out on the streets long ago, after managed care took over and the psychiatric hospitals closed; they are victims of our "civilization." In a sense, Matt was a victim of civilization, too. Dr. Haven's failure to acknowledge and treat Matt's symptoms stemmed from his own paternalistic ignorance, the false assumption that because Matt was only a medical student and he was a physician, his judgment shouldn't be questioned. Thankfully, this antequated culture of authoritarianism within the practice of medicine is on its way to obsolescence, but we've got a long way to go. We're still not doing such a great job taking care of our sick. In comparing cultures, I think those African villagers were much more advanced in their treatment of Omolare by letting him sweep their huts. They understood that the overall health of their community was reflected in its sickest member, and in giving him a daily task, they helped ensure that his life was not only purposeful, but valuable. Unlike us, they seemed to recognize that, indeed, it does take a village.
*names changed

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