Last things first

Vignettes and thought from last week:

My diet has reverted back to what it generally is when I am going solo; oats, fruit, milk and yogurt. I can get all of those here and the quality is quite good. If I purchase produce at the Green Bazaar it is always fresh and fantastic. Milk is generally > 3.5% butter fat, as is the yogurt, so I am back to my "whole milk builds strong bones" childhood.

Produce at the Green Bazaar

The downside of this diet is that I periodically get tired of cold food. Yes I can cook, rather well, but what's the point?  Friday a friend and I were set to go get some shash-lyk but he backed out. So I consulted the local expat newsletter, "Steppen' Out" published by the US Consulate. There was a concert of the "National Wood Instrument Orchestra" that night and the venue was close by. I walked there to scout it out and there on the front was a poster showing a orchestra composed of all national instruments. Sweet!

That evening I returned to the venue to find only a few folks there. I went to the ticket window, bought one, then tried the main door, locked. Well this was turning into a true adventure. I spied a young couple heading for a side entrance, followed, and found myself in a foyer of what looked like a college hall. Very nice folks us down some stairs and ramps to the basement (this is getting way cool!) and across the building to a basement room, divided in half by a curtain, dimly lit, and smelling of wet concrete. In front of about 100 empty chairs in rows was a semicircle of five music stands. I found a seat in the back  and waited, at once resigned and excited.

With complete solemnity and purpose of movement, out from behind the curtain come four men and a women dressed in period garb from the 18th century; long white curly wigs, red jackets, white shirts with frilly collars and cuffs, knee length pants with white stockings, and shoes with bows. The woman was in a huge hooped dress. One of the guys, the youngest, gave a bit of an eye roll as he sat down as if to say he hoped his friends on the audience would just listen to the music and not be blinded by the dress. There was a flute/piccolo player (the woman) then an oboe, French horn, bassoon, and clarinet. The National Wind Instrument Orchestra I assumed, stifling a laugh. The clarinetist read a program in Russian and all I recognized was "Mozart". So for the next 90min I listened politely to music I normally dislike while I marvelled at my mis/good fortune. There were young families with their kids, young couples in love with heads resting on shoulders, students, professional types, and me.

Yesterday I visited the Almaty Applefest at the "Park Named After the First President" or simply "The First President's Park" (mind you he is the only president thus far). It is a city wide celebration of the "almaty" or "apple" in Kazakh.

My favorite music makers

 I had several clinic days last week that were delightful as medicine is a "language" I can speak. My colleague, a member of the faculty at the university, generally sees only adults. Virtually all the patients have ECGs, indicated or not. Many patients have diagnoses of myocardial infarctions in the face of clean (and unindicated) angiograms.  Again we spent much of the time undiagnosing various scary maladies. As in other settings (in particular the US and more particular HI) when reassured that they weren't as sick as first informed they were often nervous and even confrontive.

The first and thus far only president

I find it very difficult to interrupt the perpetuation of not only a false disease process but also the attendant sick role that accompanies it. At home I have to be extremely gentle and politic as this can put distance between a patient and their doctor. Here I find the exercise of reassurance casts an anxious pall over the Family Physician as things here seem rather siloed. Casting any doubt on a specialist's impression might have extra-profession consequences for a physician of a "lower" specialty (read caste). At home, and here, it is too easy to see, immediately refer, and think you are practicing good medicine. I find that to be a complete abdication and struggle with colleagues that do that.

Here (and at home to a lesser extent) medicine seems quite enmeshed in regulation, both real and imagined, the consequence of the old Soviet style of care. Key to success in medicine is to stay under the radar, or stay politic, or both. Kazakhstan's health care has come light years since 1991, to be sure, but all those in power were here at independence and default to what they know (as would we) yielding a bureaucratically stratified system lacking nuance and modulation.

In the US, we have an over-abundance of specialties that are finer focused than Family Medicine. Fair enough, we are fortunate to be able to do so, I suppose, but when is enough...well...enough? Is it appropriate to have a CT/MRI scanner on every corner? Hospitals clustered within several blocks of each other with duplication of services? Non-profit medical institutions that really aren't? Urgent care is on the rise as we no longer have the type of linear medical care relationships that assure better care. If we don't see our patients when they are sick of what value are we? Here, and in other places I have been, all care seems in the context of a single visit or opinion. Follow up with the same physician and benefiting from that familiarity is rare.

Proximity of the city to the mountains

We saw a woman with a hypertensive situation needing immediate attention. She was to go to the hospital the next day as that was when she could get there and when they would see her. (I have heard many conflicting opinions about how hospitals work here and none seem particularly flattering. Still the stories have come from expats so I won't commit the comments to paper or blog.) I mentioned to my colleague that her patient could go to the pharmacy in the clinic, get a medication, take it and lie down in infusion room. We could take her BP and interval history as we were leaving and if she was not better could take her to the hospital to try to expedite her care. I could tell that my colleague wanted to refer and move on but out of respect to me she instructed her patient as I advocated. Two hours later she was out of danger. I asked her to come back the next day and her BP was fine. No where near as dramatic as treating sepsis in remote Botswana but compelling never the less.

Out my back window

Friday I took my phunky phone to where I bought it (Beeline). It was raining a cold, gentle rain and I enjoyed the walk. I was first in line as I needed an English speaking assistant before she was occupied by another customer. She had graduated from the English Language University here and had majored in same, score! She was very kind as she let me know that it was the fault of the phone and not the SIM card and that their obligation only went as far as the SIM. She wrote down the address of the Samsung service center, looked at my expression of confusion and the rain outside then decided to call ahead. They said they could fix it over the web, she took my number, and the next thing you know it was fixed! Unfortunately at the expense of all the downloaded medical data bases, contacts, etc. I walked home and and spent the afternoon tricking it out and re-entering contacts. Somewhat later I noted I wasn't getting calls. Another several hours of cussing and finally I got it figured out.

I met with two guys who are re-starting Little League here in Kazakhstan. It has a rich, if short history here and has been neglected. I will be soliciting gloves, bats, balls, and bucks from you, dear readers, later.