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