Buy more, how you say, sheet!

I often am asked how much money I make in the US. I always say that that is a conversation I don't have as there is no point of reference for comparison. I generally ask something to the effect of "suppose you made 10x the amount you make now, what would you owe your patients?" (Many studies suggest that money has little effect on the quality of medicine one practices or desire to work harder, often quite the opposite.)

Suppose his BP was 180/110 and he had a headache.

So I often ask the above question only to get nervous silence in response. Typically, I gently prod, "Well, what do you think you would do as a physician if you made that much more?" A guy in the back said, "I would, how you say...buy more sheet!" The place dissolved into that laughter that comes only on a Friday afternoon after a long week.

As Eli would say, "You can fish or you can hunt." with lab.  But not both and you better be ready to know what to do with the fish.

A delightful student who is a nervous wreck thanks to us trolling through the lab.

Teaching the neurologic exam. The students learn it once then forget it as "only neurologists do this". Note the percussion hammer. This is the only one in the clinic and it is mine. I asked her to draw a clock and she couldn't as it wasn't digital!

Here is you heart, but your pain is near your clavicle

No evidence of heart pain, let alone MVP

We saw a student in the clinic who came in to get a sense of which echocardiogram (ECHO) to believe. He was very nervous and we as doctors had very effectively created it. The short of it is that he was having chest wall pain and saw a physician who unfortunately ordered an ECHO which showed very slight mitral valve prolapse. ALL the ECHOs here are read as that. As he is a med student he read up on it, became scared, and went home to Afghanistan, to Kabul, to be seen at an Indian clinic, had another ECHO which was negative, and now confused, scared and frustrated. As an aside this student knew three languages in three different alphabets. I said that I bet we could decide what was wrong without touching him and of course we did. However even after being extensively reassured he was unwilling to believe that the pain was not from his heart. It was a great illustrative case. Ultimately I asked him to think it over and call me with anymore questions or concerns

Yesterday I actually was able to find a bike rental shop. The owner showed up on Saturday morning the worse for wear, still smelling of alcohol and tobacco but was able to navigate the rental, adjusting my colleague Zhamila's bike, and fix a flat a kid. Zhamila grew up here so knew all the back ways to various sites; botanical gardens, exhibition center and a path that went along side a channeled stream.

Everybody loves to have their picture taken and they insist that I should as well. At least the lens didn't shatter.

The water from the mountains can move with so much volume and force that it will routinely take huge boulders with it, hence the channelling.

As an American expat I get a newsletter called Stepp'n Out from the Consulate and am on the email list for cultural events. Last night was the gala for the winners of the annual CIS accordion and bayan contest. Right, the accordion. Well it ain't Lawrence Welk we're talking about here.The banyan is a squeeze box with buttons rather than a keyboard. It was amazing. I like rock and roll, blue grass, jug bands, smooth jazz, and various groups. But I am starting to love the music here. I have been to seen numerous musical events and with the exception of that screwball marching band that was an exercise in self satire, they are excellent. Ever heard an accordion/banyan quartet? Me either. Amazing. And when it is mixed with a national wood instrument orchestra the sound is amazing. It was held at the Kazakhstan National Music Conservatory and with the exception of the final master couple who were truly masters, all the musicians were <30 y/o.

You know how really good instrumentalists can touch keys so efficiently that you barely see their fingers move as they play 128th notes? These banyan players were the same.

SCORE! and BUSTED

News flash: My local grocery store just got in a small supply of peanut butter and now it would seem that it’s gone. Gone to me baby, at least the chunky variety! I now have enough for the next three months if I husband the precious chunky hydrogenated artery clogging stuff.

As I type this on Thursday 23 October I have no electricity and yet it has been a great week. I have been teaching at the Kazakhstan National Medical University Medical Clinic where interns are trained. Internship is now two years and is exclusively in general medicine (Family Medicine). All this can change with a signature but for now it would seem I am in the right place at the right time. While I’m sure there are some subtleties I don’t appreciate, this situation is consistently professed by all of my academic colleagues. It would seem I am in the right place at the right time.

I navigate my way to the polyclinic via bus in the morning, teach in a clinic for m ill medical students, to medical students, then lead a discussion based on a case that I saw that morning or invent one for the sake of skewering the students and interns. I’m not that much of a professorial nightmare, I just hated lectures as a student and this is way more fun, at least for me. We discussed asthma and how it can be both the same, and different, as COPD. We also discussed smoking and how it is a huge problem both here and in Kentucky (Kanetookyeh). I was at once amused and reassured when I suggested that most people with COPD in exacerbation should be on an antibiotic only to provoke a great hue and cry about why should we do this when it is a viral infection. I tried to point out the evidence and that yes it is controversial most times but perhaps not here…nope, gloves were off and I was in for a lively discussion. Shouting in Russian must be fun.

As it turns out you can get anything want at Alice’s Restaurant (read pharmacy) INCLUDING Alice. Here you can get antibiotics, almost anything for that matter, without a prescription. To me the great unknown is not whether MRSA exists here (it must) but how bad. (There is gross under reporting of disease here. So if the data is inconvenient, it isn't reported.) Often we will see patients with a cold who have already been on several antibiotics, all of them are broad spectrum as these are the most expensive and it is in the pharmacist’s best interest to both recommend and sell them. In the US physicians are all too often complicit in this exercise to wit: "I get sinusitis twice a year and my doctor always gives me a Z-pak." Wow just writing that makes my gut turn.

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Each day in the clinics brings another classic teaching case. As was the case in the US a generation ago, depression is a diagnosis of exclusion in the CIS. It is not at all unusual to see a woman who has had a mega-workup for everything from dandruff to athlete’s foot. Navigating the previous misdiagnoses and applying this new one is challenging even when I can speak the language.More so here as in Soviet times it was viewed as a sign of weakness and still is to a large extent.

Today I saw a tragic case of Spinal Muscular Atrophy (SMA) in a beautiful 10 month old boy. This was the first time I had seen it and the pediatrician just wanted validation about the diagnosis. To my surprise he had been very well evaluated and the genetic testing was pending. But he was right out of the text book; onset at three months in an otherwise beautiful child, floppy paralysis legs>arms, no muscle tone of the back, progressive loss of facial expression, etc. The child will most likely die before age two, likely from respiratory failure. Folks in medicine here can sometimes be rather Soviet in their approach; cold blooded. In other words, “You have ………, this is the prognosis. Good bye” I have seen this is all venues I have lived and it is least excusable back home. We discussed how this mother already understands the prognosis but she needs to hear how we will do whatever we can to maximize his life and how we will always be available.

I made several home visits on Monday as part of a survey for obstructive airway disease sponsored by Glaxo SmithKline. It is one of numerous studies undertaken in the CIS to screen for disease or pre-disease. The cynical side of me worries that the data will either be “lost” or exploited to maximize use of various pharmaceuticals. I went with two younger women colleagues both of whom stand no taller than about my rib cage. I was treated as the aged one and with unearned respect; given a chair to sit on and a bag of fruit on the way out. I really like this culture.

I’m burying this next vignette deep in the blog in hopes that my family gets bored before this point. (If not I am already > 10 time zones away, so I might be far enough away to have a bit of a  head start.) Since I arrived in Almaty I have had bothersome eye irritation; itching and a gravel sensation of the eye lids presumably from all the smog and dust (most likely allergic conjunctivitis). This morning I thought I would inquire of one of my colleagues about eye drops. She is an ophthalmologist which means she has had 5 months of advanced training after her two year internship. As I am a guest, from the US, old (so I have been informed), and a professor (whoulda thunk, me) simply giving me a little guidance wasn’t enough. She asked my interpreter, Jhamila, a gastroenterologist, something in Russian provoking laughter throughout the office. Jhamila shyly asked something to the effect of didn’t we have saying in America about how a “doctor shouldn’t treat himself because he is, how you say, a fool?” Busted. I acknowledged as much and asked where I could get the (damn) drops. Nope “you need to be examined first!” This was going south fast. So amidst a bunch of giggles (the VAST majority of physicians here are women) I was trotted down to the ophthalmology office and ultimately, with great ceremony, was informed that I had allergic conjunctivitis! And these are the drops you need…

Sweaty nether regions, they named it right, and dude you can't just quit!

Earlier this week a couple of good friends and I went to the local "banya", colloquially know as the Arasan Banya. One queues up and can rent slippers, towel, and wrap. My friends had come with suits and towels. I had just come from what is called the "American Corner" where I had had some fun at the medical students expense but more about that later. We entered an ornate domed building and ran the gauntlet of guys offering massages. No homo eroticism, just a guy trying to make a tenge.

The first stop was the Finnish Sauna, dry heat. We got a good sweat going and headed to the pool where we jumped into about 60 degree water. "It's good for the circulation!"said out host. "Yeah but exactly to where?", I thought as I was experiencing some acute discomfort in my nether regions. Then to the Turkish steam room.  Steam and more sweat. The Banya has two floors, one just like the next so my host took us to the least crowded one where we chatted until my "circulation" was in full on red alert mode. Again to the pool where the "guys" heaved a notable sigh.

One (willingly) holds onto the rail as he is beat with a birch branch. Note the hats and the furnace in the back.

Then to what can only be called the CIS version of Dante's inferno, the Russian (naturally) sauna. One enters after one purchases some birch branches. One passes the furnace that looks like a huge pizza oven and selects which level (heat) in the room one can tolerate. Then you have some guy who it seems stays in there for this purpose flagellate you with the birch branches. There is definitely a rhythm to this, ending with two slaps on the butt. I was amused and didn't partake as I was too busy concentrating on taking my next breath. Guys who obviously know what they are doing come in with hats covering their ears. "Wimps" think I. Then some guy walks in with a bucket of water and takes a stick with a metal cup at the end and sprays the rocks in the oven.

The effect is a little like eating a habanero pepper. First you think, "What's the big deal?" Then in about 15 seconds it becomes clear why the regulars are wearing hats; your ears feel like they are melting off your head! Ahooogah, red alert! I fled and welcomed the "douche". Then off to the restaurant for tea; a bunch of guys sitting around with trunks or towels or nothing eating and drinking, in our case tea, Then rinse and repeat ending in the Turkish bath where you lie on a heated marble slab. One of our group was scalded. I came home a touch worse for wear and slept more soundly than I have since arriving.

Yesterday I had some time on my hands so I naturally thought "Gee what sounds like fun? I know I'll take a trolley to MEGA Mall!" So off I went to see a little more of Almaty than my daily existence and "the mall" as it is referred to here, not unlike Oxmoor or Clackamas or Lloyd Center or Ala Moana. Well they named it right, its the biggest I have seen. While I'm for some reason embarrassed to admit this, I have been to Mall of America when we were at the University of Minnesota for the Big Ten Swimming Championships (so its Bethany's fault). Mega seemed bigger. And of course there was the requisite food court where one could choose between Burger King, KFC, Hardees, and the standard sandwich-Japanese-Chinese type places. Guess which was busiest. This is Kazakhstan where everyone is svelte and beautiful, just like Botswana,...

I really don't enjoy crowded places in general let alone where I can't speak the language so I went to Hardees which had no line and ordered he meal by number (whew). I was asked if I wanted to "super size it", declined, and dove into a juicy concoction with way too much barbecue sauce and mayonnaise; just how I like it.

All over the world US embassies sponsor "American Corners" in local libraries. The consulate here is particularly proud of the one in Almaty. It is literally a corner of the library where you can use computers, read the latest about the Kardashians, and peruse the New York Times. English speakers give presentations once a week to those that want to come. Mine was on first aid for cardiac arrest. I had some fun with some medical students that made the mistake of showing up.

The scenario was that someone collapsed on a bus right next to you, now what? It went from there. I moved them through the scenario and had the bus pull up to their stop then asked what they would do, get off or continue? One guy made the mistake of saying he was late and was getting off because the guy on the floor was going to die anyway. That in all probability was true but the deriding laughter from the audience gave him pause. It was a hoot.

Today I conceded that: 1) I hate ironing, 2) I have not choice but to iron, 3) So I had better get one. I had been using a petite iron (are they even called that?) and the table in the kitchen. The new one and the new board made it easy. I also learned that what I think is the "warm" setting on the washer is not, its hot. It bled the color out of my favorite shirt and now I have a bunch of pink underwear. 

I miss Lynne on so many different levels and now here's another one. Thanks for all the ironing babe.

WKSMU, it's all your fault, and play ball!

I'm the tall bald guy in the back. This is a science club at WKSMU.
Not sure what the raffle is about. Note all the name tags, these students were
all participants in the displays and were docents as well. Madina on the far right.

This last week was (finally) full with consulting and teaching,  travelling, and baseball. Monday and Tuesday I spent in various polyclinics and at a local private one. The cases we saw were fascinating and quite difficult, but we were able to get our arms around them for the most part. As in many cases here, as well as in the Louisville area, when there is a vexing case the patient will often be referred early or self-refer causing confusion all around.

The private clinic is owned and operated by a Kazakh family physician couple and separates itself in that is has equipment that you would find in any Family Physicians office in the US. All the other clinics didn't have an otoscope. The owners were trained in the US. Unlike anyone else in their position they chose to return to minister to their countrymen.

Medical students of various levels

In an ideal environment the Family Physician should be the hub of a spoked wheel with all information returning to the medical home to be interpreted and seen in context. Too often there is referral from one specialist to another bypassing the Family Physician  and all context and insight is soon lost. Many folks will leave Kazakhstan for Israel for evaluation and treatment.

Cross section of a cell made with colored rice!

By the time they return all is confused and lost between three separate languages, alphabets, paradigms. And of course your patient anticipates that you will be able to immediately integrate all of this. That level of frustration, for both parties, is an every day presence world wide.

Wednesday through Friday I went with the Kazakhstan Association of Family Practice to Aktobe, out on the steppe in Western Kazakhstan for the national convention. We stayed in a classic Soviet style hotel where you might be lucky if there was one right angle in the room. It occurred to me that the room key I was using had probably been in use for over 30+ years. It was well warn and the lock would only open if jiggled just so.

My hands teaching how to
 do a vertical mattress suture.

I was interviewed by the press and local television stations with rather loaded questions such as "Doctor what do you think would most improve health care in Kazakhstan?" Now everyone knows its physician pay but they wanted me to say so, so as gently as I could I did. Well now the door was opened and trying to avoid a political mine field as the questions came at me was a difficult challenge. I think, but of course am not sure, that the interpreter took some liberties such that few feathers were ruffled.

The school was full of truly bright and highly motivated students. The entry hall had numerous displays of various fields in medicine with students standing behind them.  Every single one of the visual aids was hand made. They knew their subject cold, were unpretentious and very inspiring.

I was going into the first session when a student guide (they dressed in uniforms) took my arm and said that she was learning English and would I like an interpreter?

Madina, 5th year student
and interpreter.

So Madina and I went to all the sessions together where she was a huge help. There were times when she would editorialize extensively so, as Bethany would say, I would "just smile and nod, smile and nod".

The assembly was very progressive and enlightening. I gave a lecture on health care in Kazakhstan as I saw it and it went very well. Below are some of the hand made displays

Right and left heart and circulatory systems

Hepatobilary system

                                                                                                         

The heart (in clay)

Stages of labor in textiles (!)

Me doing my best to be astute. We were discussing family medicine training

That evening I watched TV for the first time since arriving. Were you aware that America is at fault for everything from global warming (true) to ring around the collar? Did you know that the Americans were buying a glacier from Afghanistan by way of cynically inserting cash into the economy, stealing their water and then selling it off the ship (presumable there will only be one) to the poor and thirsty? Or that a USAF fighter jet shot down the Malaysian airliner over Ukraine, not the Ukrainians, and the Americans are blaming the Russians to cover it up? Oh and we know where the other one is but aren't telling anyone. I am completely willing to acknowledge that we have our own form of propaganda (see Fox News) and deserve a political dig for the messes that are Iraq and Afghanistan, and maybe we did invent ring around the collar....but the glacier was a good one.

Finally, more baseball today: Cool and crisp. The ball would roll into the weeds and just stop. Great day indeed.

Top left: Cuban and daughter, Cuban in Russian hat and Cuban uniform in Kazakhstan, Cuban, Kazakh, Cuban, American, slightly hung over Kazakh. Front left: Kazakh, Korean, Kazakh.

Our field. Note only two bases. The foul lines were marked with plastic shopping bags and were 10 poles into the field on each side.

Of course there is the after game smoke. No doobie this time.

To quote Calvin (not that one, the one of 'and Hobbes), his Highest Excellency, Supreme Leader for Life of G.R.O.S.S (Get Rid Of Slimy Girls), "Is this a great club, or what?!"

Tour of Almaty

The week has been revealing on a number of levels. Early in the week I mentored a doc at a local private clinic. I may have said before how many countries with a single payer health care system will also have a parallel private system that affords convenience of schedule and a sense of better care. This particular clinic is out of Israel and, like in the US will sign up various panels of patients via their employer. The physicians they see will have had the same level of training as the public sector but the setting is better and everything is under one roof. They also make home visits, a modality begun during the Soviet era when they were cranking out a gazillion docs with nothing to do. Incidentally some went years without pay in the early 2000's

Finally, a clear day with a vision of the Tien-Shan

The family docs here fall into what I consider to be the same rut that some of us in the US do, gate keeping. As an example an elderly woman (not much older than me come to think of it) came in for an examination of her abdomen as she had had pain for the last several weeks. A complete chemistry panel, abdominal ultrasound, U/A, and CBC were ordered and she was now there to see the physician, a "general practitioner". Often these practitioners will have all of two weeks of pediatric experience which is OK as they don't see peds, OB/GYN or anything other than minor and stable adult maladies.
The ultrasound read that she had gall stones, an hepatic cyst, a renal cyst and stone and enlargement of the head of the pancreas yielding the following diagnoses; hepatitis, cholecystitis (inflammation of the gall bladder, cholelithiasis (stones of the gall bladder), pancreatitis ( a diagnosis made clinically and with one lab test that wasn't done) and pyelonephritis (a severe urinary tract infection that can be fatal if not recognized and treated). All of the lab was essentially negative except for white cells in the urine indicating a UTI. She was being referred to a nephrologist and a gastoenterologist.

As diplomatically as I could I asked if my colleague truly thought she had all these diagnoses and if not which ones she really did have. A bit of a blank look and a hint of fear crossed her face.

An editorial comment: If one wanted to control an environment one would use arbitrary rules enforced arbitrarily to do so. The GP's (I really bridle at that term but here it is appropriate) are typically scared to buck the system as they understand it and test and refer early and heavily. If they don't they fear that their pay, VERY meager, will suffer.

The Start

I pointed out that she had a UTI for sure and the all the other stuff was fluff (OK I didn't say fluff). If she wasn't treated for her urinary tract infection she might indeed get pyelonephritis. Folks in her (OK, our) age category don't do well with this, especially if she has a stone. So we treated here for what she definitely had and will see her back for a repeat U/A (they don't culture) in two weeks.

Friday was fascinating. The polyclinic where I spend a fair amount of time held a news conference for yours truly. I discussed what it was to be a Family Physician in the West and how things here were at a cross roads wherein more comprehensively trained family docs will take health care to the next level especially in the rural areas. Free health care isn't. Well it is if you have a cardiac procedure for which you would pay a huge sum in the US, not here. But primary care we should be trying to "keep the patinet out of the hands of the consultants". Also there is time away from work/family, travel and he inevitable clinical malaise that has stubbornly remained after independence (read Soviet paradigm). As a quick side note I am told that if one asks if the ethnic Russians here miss the Soviets they almost to a person respond yes. And many are Putin sympathizers,

Next was a conference with the staff at the polyclinc. Primary care here is practiced by women, almost exclusively. In a room full of physicians there were four male providers (nurses and the like). This is the way it is nation wide and there is isn't consensus about why, everyone takes this as the status quo. The medical school classes are about half male but all of them are skimmed off into the pharmaceutical industry.

Last night was the wedding celebration of Timur, my friend who is starting up Little League. The classic celebration is fairly the same as many in the US, with the exception of traditional dance, narration in Kazakh and Russian, and some interesting parlor games. I met several docs there (interestingly all male) who are specialists in pulmonary and cardiology. Food was plentiful as was hooch and wine. The wine was Kazakh and very good. The vodka was, well it was vodka and got some folks "there" in more of a hurry than the wine. We ate besbarmak a dish of boiled horse and mutton on a bed of flat pasta. I've seen the item in the foreground in Afghanistan, it was an honor to be chosen to eat the brain. I was honored and we'll leave it at that.

Today was way cool. The Tour of Almaty is a top flight bike race. The winner of the Tour de France  is on Team Astana and was here. The race was six laps along a closed course totaling 186km (115mi) and won by a member from team Astana. It looked like it was rather handed to him at the sprint as the 2nd and 3rd places were Russian.

The weather was clear and dry and the race was fast! Probably an average of 30mph. And after the race no one that I saw was even out of breath!

The guy with the Italian flag on the left is Vincenzo Nibladi the winner of the Tour de France

OK here I am in A'town, at a bike race, and there is someone wearing the hat of my favoirte team, 13 time zones away.

Victory stand