Guest blog by Jessie Kittle
Seven years of advanced and expensive training in the US has prepared me to be an attending in a few months. Particularly in my practice setting, expensive and complex interventions are the norm and sometimes benefit the patient. I’ve recognized throughout the years that the system that shaped me has some serious flaws. Health care access is often disparate, and we spend more time facing the computer than our patients. Futile care at the end of life and over-utilization of expensive interventions are common, and the bankrupting of patients occurs regularly (and beyond the view of doctors who contributed). I have sometimes felt my passion for this version of doctoring wane, and I came to ASRI seeking the holistic ideal of connecting with patients and improving the community with my practice.
My first impression seeing patients was a strong discomfort that I can’t see inside of you. Without all my usual tools I felt like patients’ problems were a mystery, augmented by my inability to gather a history in their native language. I felt the need to know patients' renal function before prescribing an ACE inhibitor, get a TSH result for a patient with goiter and hyperthyroid symptoms, to see the pneumonia I was diagnosing on x-ray. I felt nervous that my digital-doctoring skills had replaced my human ones and that I was obsolete in this environment. Sometime during week two I made a diagnosis of heart failure, a diagnosis I’m very comfortable with given my extensive training on the subject. I thought, "Ah, I can see inside you!" Victorious, I began trusting my excellent training on the physical exam, and I was off and running.
The patient cases varied from routine to shocking, which is typical anywhere, but most striking to me was the result of the perpetual comparison of, "If this patient were in the US, we’d…", since the answer was often a lifesaving intervention that wasn't possible. A 63-year-old woman with a major heart attack would have been in the cath lab within the mandated 90 minutes at Stanford. Without that intervention her mortality rate doubled. Despite that, she improves each day and I smile encouragingly, hoping my eyes don’t betray me and say: "I’m worried, and I’m sorry I can’t offer more." But it was also a lesson in the resilience of people; often times our insistence that a patient needs what we recommend and will suffer great harm otherwise got turned upside down. A pregnant patient with pyelonephritis declined antibiotic treatment after 3 days and we thought she would certainly become septic and possibly lose the baby (and told her as much). She returned a week later... and was perfectly fine! Perhaps she took a gamble and happened to win, but these situations were a great lesson in humility in medicine. An 89-year-old man came in with stroke symptoms and there were no diagnostics or interventions that we felt could help him, so the family decided quickly to take him home. Our ambulance driver drove all night to deliver the man to his home, to die. I was conflicted with the discomfort of not having a CT to really explain what happened, and not being able to admit him for at least some IV medications, speech, and PT. But on the other hand, I'm not sure all the expensive interventions would have amounted to anything but him dying somewhere other than home, leaving his family with insurmountable debt. It was yet another humbling moment for me as they drove off into the night.
I felt deep satisfaction in facing a patient, both of us barefoot, using hands, eyes, and ears to peel through layers of medical and human knowledge to craft a diagnosis and treatment plan that worked for the patient. I made a connection to the humanity of doctoring, which is what interested me in medicine in the first place, and that I hadn't experienced so purely since I was a medical student in New Orleans (caring for only a few patients at a time). It's not that the humanity is absent at home, it flickers in and out of my day like a ticker tape on the bottom of the perpetual computer screen of medical care. But here it was palpable around every patient, and reconnecting with that feeling was very powerful and timely as I set out to start my career.
The conservation model that ASRI employs was another incredible draw for me in pursing the Johnson & Johnson Global Health Scholars Program (J&J) in Borneo, and was even more impressive than I expected. I have been an environmentalist my entire life, with years of experience in wild animal rehabilitation and marine mammal training for conservation research. I loved attending Etty's education seminar, where she skillfully drove home the critical connection between the health of humans and the natural world, and ASRI's multi-pronged approach to these objectives. I spent a day with the Goats for Widows program and saw the gratitude of the families who benefit so greatly from the independence and financial security of the program. The reforestation program was of a scale I didn't imagine, operating as a living-lab in addition to a conservation project. This was health care not just of people but of the earth, and has providing me with endless inspiration for working toward a better planet as a physician.
Clearly, I will take much more from my time in Borneo than I could ever give. For that, I will forever be indebted to those who ushered me on this journey. Huge thanks to ASRI, Health In Harmony, Nomi and Vita, J&J, Stanford, Yale, and Dr. Kinari for creating this reality and allowing me to share it, and to the patients on the treasured island of Borneo who made this experience so fulfilling. Till we meet again.
About Jessie Kittle
Jessie recently completed her residency in Internal Medicine at the Stanford Medical Center and volunteered at the ASRI Clinic through the Yale/Stanford Johnson & Johnson Global Health Scholars Program in April of this year.