Clinical Judgment

Well, that went quick. All of a sudden, we’ve just finished our last day of clinic. It’s a bit of an abrupt ending, too; usually we go every weekday, but a combination of special opportunities and somewhat perilous political situations will be keeping us out this week. Tuesday and Thursday we’re off to a nearby refugee camp and a leprosy clinic, respectively. And Wednesday…well, Wednesday is a bit of a toss-up. After canceling them earlier in the month, the Malawian opposition has decided that their protests are now back on, and scheduled for the 21st. Most of the ex-pats and Malawians I’ve talked to don’t seem too impressed; we might end up staying home in our compound for the equivalent of a loud town meeting. But then, given that the last protests ended in 20 civilian deaths, seems like it might be better to err on the side of caution. We’ll see.

In any case, today’s clinic was a nice snapshot in terms of the most important things I’ll take away with me from this odd little rotation. For one, regardless of whether I’ll ever use it again in my future career, I’ve become pretty confident in my tropical derm skills. Chicken pox? Pellagra? Nima-soap-induced skin reaction? (Nima is a brutal soap used here.) I’m on it. Rashes are my cup of tea. I got to see only the most rare and exciting patients for three weeks, with virtually none of the boring! It’s like eating only the top of the dermatology muffin! Working in the clinic here reminded me of all the fun parts of derm that appeal to me – while simultaneously reminding me how infrequently these types of derm patients show up in the US dermatologists’ offices. Just what I wanted.

For two, this has been one of the first rotations where I’ve actually been a teacher as well as a student. The medicine hierarchy puts third-year medical students at the very last rung on the ladder; they are there only to receive wisdom, not to pass it on. (I actually got reprimanded last year for trying to remind a patient what had just happened in her recent surgery. “You are here to watch and to learn, and nothing else,” my resident yelled.) But this month, amazingly, there were people around who know less than I do. I shared a clinic room with one of the second-year students for two weeks, and I tried my best to be like the senior students I loved during my early years – full of information, not overbearing, willing to let the younger student try her hand at some smaller tasks and take credit for any successes we had as a clinical team. The last one is particularly hard, I found – it’s hard to not want all the glory for the application of your hard-earned knowledge – but I think I got better. We also had Malawian nursing students with us, rotating through for a week in their training. Teaching through a language barrier is extra tricky, but I was really happy with the way our morning with today’s student turned out: after I took the time to explain all about herpes zoster (aka shingles) for an early morning patient, our student triumphantly identified a second zoster patient who walked in a few hours later. There were high fives. Instantly gratifying.

And then, as with every international health experience, there are the moments of doubt. On Saturday, our visiting surgeon had operated on an albino woman with several horrific skin cancers on her face. Two cancers came off rather simply, with an elegant skin flap to cover the open space on her cheek, but the third…the third was a monster. Almost 7 inches wide, it clearly had been growing for years and looked like it actually reached down to her skull in the center. (The patient had taken to simply covering it with a head scarf at all times – we didn’t even realize it was there until someone finally thought to have her take it off.) Our surgeon decided to operate on her, even if there was only a partial chance of a cure – with her skull exposed like that, it seemed like only a matter of time before the cancer crossed through the bone and gave the patient meningitis. But during the operation, after cutting carefully for a few hours, our surgeon realized that the cancer was already in the bone. Simply removing the skin around the cancer would do no good. So we sewed the patient’s forehead right back up, and sent her to the general hospital for wound care.

Today, 48 hours later, we saw her back – and her face is clearly infected. Part of the skin flap has died and turned black; there’s nothing to do for that except wait for it to slowly scar over. Wound care at the hospital has been less than ideal – she didn’t have a fever yet, but there was pus and a distinct odor around the stitches.

We’ll start her on antibiotics, and hope that her sisters at home can do the diligent wound care that she’ll need for the next few weeks. But I really found myself wondering – what have we done? This woman was in no pain before we took her to the operating table. True, the smaller cancers are gone. But the one that’s going to kill her is still there, and untreatable in Malawi. And maybe we’ve even shortened her lifespan by exposing her to these infections. And next week, the two main doctors involved in her care will be half a world away, back in the US, inaccessible.

Part of me feels that to do nothing, to not have tried to remove the biggest cancer, would be just as morally blameworthy, if not more so. But it’s hard to reconcile the fact that, all things considered, her outcomes are no better, and probably worse, than if we had never treated her at all. There are many other patients that I think were genuinely helped by our presence here, but it’s hard to remember that when you’re looking this poor woman’s face.

Learning, teaching, then reevaluating your work in an ethical light – a worthwhile clinical experience, overall. Looking forward to the refugee camp tomorrow.