PendlehomeKZ: The outside is gray like all the big buildings here. The inside....well you decide. (Pics at the bottom)

The tour began in the peds ward. I had asked to be shown the hospital to which the Family Medicine Department is attached. It is the Regional Hospital in Semey and is the referral center for what we would call primary and secondary hospitalizations. The exterior is classic Soviet era functional grey concrete block, 7 floors, 200m long and not particularly inviting unless one has no other option, and one doesn’t.

We visited the peds ICU and adult and peds general wards. The rooms are large with five beds, a sink but no bathroom, and quite warm. Folks can receive what amounts to folk medicine or meds used off label as there isn’t a shred of evidence for its use other than anecdote and that just has to change. This hospital is huge and covers all the specialties a western one would. However it needs to be huge as the average length of stay, while I’m not sure of this, must be > 10 days. It is usual to be admitted for two weeks for a problem that is poorly understood by the patient as well as staff, have unending tests run, and leave without a clear sense of why you were there in the first place. Hospitals aren’t safe environments anywhere in the world and as I recall the US has tens of thousands of deaths from hospital error per year. It must be as least twice that here but there are no records kept for this so who knows. Regrettably an acquaintance of mine contracted Hep C from dialysis here.

I will consult on a patient with the students or interns after a lecture and generally the patient’s physician. Larger places like this one toss patients my way out of a desire to teach and respect for me. Word soon gets out and folks line up to “see the American doctor”. Such was the case today. She is 73 and here for no other reason than she heard that I was. Without her doctor’s blessing she wants to be seen for the Kazakh equivalent of being “checked out”. Full disclosure, I hate this, both here and in the US, as with some folks no amount of reassurance or invocation of common sense will be enough and if they don’t leave without an antibiotic or pain med the doc is detested for practicing evidence based medicine. Here the dance is to be careful to offer a learned opinion without undermining the physician she sees. Well it turns out she doesn’t see one very often so the brakes were off as it were.

She was feeling poorly so she called a physician to her home for evaluation. Many folks here take their blood pressure at home and note that if they feel uncomfortable they have elevated BP, but not by any significant amount. So if their BP is elevated they start looking for symptoms and see if any stick; both the patient and the physician. Well it turns out that she was complaining of everything from headache to jock itch to athlete’s foot. So without touching her the home treating doc ordered an EEG, EKG, abdominal ultrasound, and endoscopy. Now I have been here long enough to have my gene for cynicism rear its ugly head. Without looking at the chart I predicted that she had; chronic pancreatitis, chronic pyelonephritis, and would have had chronic cholecystitis if she still had a gall bladder. On the money. Everyone laughed. And the EKG showed “ischemia in one lead”, yep. And the endoscopy showed “atrophic gastritis”. Man I’m headed to Vegas next.

I had the students do the history and physical and they were outstanding. They really are starting to get it after only two weeks. They are intimidated by a huge, overstaffed, officious, authoritative, Soviet hangover that is the medical establishment. To be sure there are bright lights out there but until more docs and officials retire, there won’t be substantive change. Like my father used to say after a glass or four of wine, “Not enough people are dead yet!”

My point to the interns is that you are as obligated to undiagnose as you are to diagnose, and try not to be intimidated as you are well within your rights to simply play dumb and ask your colleague why she (medicine here is a total matriarchy) thinks that is the diagnosis. Now to be sure too many docs in the US order way too much lab without indication and for the same reasons that they do here; fear and ambivalence. So here she was with all this confusing lab and no one to interpret it for her.

I always tell my students here that the lecture hall is a safe place to be wrong, so commit (dammit!). They slowly are willing to take that risk and today was a true break through as all 35+ coached, laughed, stumbled, farted, and fell down but got the job done. I was giving fist bumps all around. Our patient was having a gas and was showing her 8 gold teeth widely to all of us.

And of course it turned out she had none of the above. But rather had mild hypertension and well-earned osteoarthritis of her knees. Interestingly she had ordered one of those magnet bracelets off the internet (whod’a thunk?!) and used it for her hypertension. So I had the students weigh in on its benefit. We took it off, checked BP, and replaced it, and checked again. I asked if there was any evidence that this worked, anywhere. One of the students said she had seen it on TV so it must work. We howled as I gently cited the difference between anecdote and evidence.

So “now what”, I asked. One of the students brilliantly and gently informed her that she was truly OK and that while we couldn’t predict how long she would live she should look forward to a healthy life. My jaw dropped and I welled up. Wow. She looked at me and held out her fist for a bump, I gave her both fists and the students applauded. The patient loved the attention and left satisfied.

Back to the hospital. It is a step below Princess Marina in Gaborone, Botswana and even primary hospitals in Botswana. Until the whole central control BS vanishes it will always be that way. But today I saw a very distant shining light on the medical education front that validated my purpose here and had a brilliant intern demonstrate the art of medicine to her peers as well or better than I have seen.