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…