Why I left clinical medicine behind...

Perhaps the most striking difference between being a Pathologist here in Kijabe versus the US is the amount of patient contact I have.  Except for a few specific scenarios at home - mostly transfusion medicine related - at home I pretty much go through my day without interacting with patients. When The few patient interactions I do have are usually helping them find some part of the hospital or sharing excitement over the grilled cheese sandwiches we all just ordered*.  Here, things are quite different.

The first difference is that in order to get to pathology, you have to walk through a moderately sized and often very crowded waiting area.  I literally cannot go to or leave the lab without passing at least 50 patients and their families.  I've already mentioned in a previous post how, as a white guy (with or without wearing my white coat), this can rapidly get you pulled into helping a patient.  It's also humbling to see so many people waiting so patiently for medical care.  (I assume this process is actually just as frustrating and boring as it is for patients in the US).

This week I have a few more patient interactions, mostly unintentional.  A young woman, a nurse, came by the lab on Monday to get results on a peripheral blood smear.  I was grossing the day's specimens, wearing my smock and scrub top, and had not yet looked at the slide.  When I asked about the clinical scenario - "what's the question to the pathologist" - and she told me it was actually her sample I immediately doffed my gear and brought her into the office while I examined the slide. I could tell immediately from the blood cell counts and coagulation lab tests that a serious diagnosis like leukemia or bleeding disorder was very, very unlikely.  I was able to reassure her that the smear looked normal and that she needn't worry.  This was the most uplifting patient interaction of my week.

Today I got hit three times in a row.  In the afternoon, a man I know from the hospital here stopped by to speak with me.  We made polite conversation, asked how each other was, and then I asked what I could do for him.  He told me he wanted to follow-up on a biopsy specimen for a woman who was having increasing difficulty.  I knew that we had seen only two biopsies of this type today and both had nasty, invasive cancer.  My face fell when he revealed this was not just any patient, it was his mother. We talked for a while. There are few good ways to deliver bad news. After he left, I sat in the office and cried.

Later this afternoon, after the staff had left, I was working on a blog post that will appear in a few days.  Two patients appeared in rapid succession.  The first spoke little English, had already paid to have a fine needle aspiration of her thyroid performed, and had been directed to Pathology.  In our broken pidgin I was able to direct her to Radiology - right next door to us - whom I believed would perform the procedure.  They could at least speak in her language and direct her to the right place.

Immediately on her heels was a petite woman, probably in her 60s, who was emaciated in the way that only chemotherapy, HIV, and TB can produce.  She had arrived to pick up a block of formalin-fixed, paraffin-embedded (FFPE) tissue from which we had diagnosed her invasive breast cancer over a year ago.  I spent quite some time trying to find our tissue archives from this far back, but alas, could not help this woman and asked her to come back in the morning.



I love medicine.  I got enormous satisfaction from working with patients when I saw them regularly as a medical student.  At least at times, I think I actually did pretty darn good by my patients.  And sometimes people who were not my patients - or were not even patients themselves - but for whom I was the right person to talk to at the right time.  There are actually a lot of reasons I left clinical medicine, but one reason is that I could never find a way to interact with patients, be emotionally supportive, and not feel their pain too deeply.  Respect to those who can, but it isn't me.

Pathology is usually much easier in this regard.  We hear and read all the terrible stories.  We see the terrible cells that are killing our patients - indeed, we know their diseases more intimately than any other physician.  Mostly, we shake our heads and feel for the patients but are liberated from the immediate, emotional pain.  Then there are days like today.



*Seriously - this happened.  There were three women behind me in line for lunch shortly before leaving for Kijabe.  We all just happened to order grilled cheeses... mine, at least, was delicious.