Reflections

I look through last year’s journal entries from the time I started at Nkhoma Mission Hospital, the time I started working with residents and seeing patients on the Medical Ward. “A much longer day than expected” progressed to “exhausted” and then “came home and cried and cried” within the first week. “Such sick patients…Too many deaths” I wrote. Within days my physical state started deteriorating. “Twisted my ankle,” and “I got sick this morning,” in my second week bloomed into “sleep deprived…heartbroken” and then a full-blown “I was in despair.” By my third week, I had ulcers in my esophagus which kept me from eating, drinking, or sleeping. I remember feeling bewildered at the time, knowing that I had come here to do public health and improve systems, knowing that I didn’t want to be in charge of patient care day after day if there was nobody to help. I had so much training in avoiding burnout and not carrying the world on my shoulders. I’d given lectures on it and planned my career around equipping others and getting buy-in so that my ministry didn’t begin and end with me. In my head I knew things were terribly off balance, but in the context of staff shortages and clinician strikes, I just couldn’t fight my impulse to take responsibility for patient care.

But it was true, the patients were so sick, and there were many days when I was alone. I still remember the young man with such advanced leukemia that his blood was white and cloudy instead of red. The family didn’t want to tell him, they didn’t want a chaplain to come and pray, didn’t want him to go to the city for further treatment. Those were hard days, just learning the system and having to make those big decisions. I might have given up in the first month, if I hadn’t read some writings of Mother Theresa and decide that if she could provide love to the critically ill and dying. That was her entire ministry, she didn’t get a chance to heal or discharge some like I did (well, at least, by the third week I finally saw a patient go home instead of being transferred to the Central Hospital or the Morgue.) Even if I preferred to be a doctor who was preventing these diseases, I could try to be faithful in this situation.

After the initial heart-change, there was a simple systems-change that made everything a bit better: I made a list of the patients. It sounds like something so simple to someone with Western Medical training, but it just wasn’t how things were done at Nkhoma. But with a list, I could at least know who the patients were and how long they had been there. I could direct students to see each, even if I couldn’t fully evaluate all 30. We were able to send 9 patients home that first day, once we knew as a team who they were and why they were there. More than that, now I knew these patients’ names. We could pray over the list in the morning and then pray for the patients throughout the day. Even my resident started feeling comfortable praying for patients during that time.

A lot happened in the last year. Now I find myself back on the medical ward. Seeing patients here hasn’t been my primary job for the last 10 months. I’ve still been involved in helping the ward improve documentation and have watched mortalities decrease for the first three months, and then increase during the time of COVID. We’ve had weekly tea parties and periodic celebrations during all of those months, during the changes in staff and leadership and through different policies. And now I’m back a couple days a week, supervising our senior resident as he learns how to be a leader on the ward. Last week he told me, “they teach us in school that the patient always comes first…but if a doctor doesn’t care for himself, how can he keep giving good care to patients?” I smile. I still lecture frequently on boundaries and burnout. But at least now I’m practicing a healthier balance myself.

One day my resident said he was ready to discuss the patients. He is using a list which helps track how long the patients have been here, what they have received, the likely causes of their symptoms, and the plan for getting them better. After discussing the patients, we review what needs to be done for each. We even charted them on table to identify which were the most important and which were the most urgent.

There is a patient who doesn’t have much longer to live. She had a stroke a couple weeks ago and can’t swallow. For a while her breathing was improving, but now it’s taken a turn for the worse. Maybe she has hours, maybe she has days, but she won’t last minutes without oxygen, and there is no way to continue oxygen unless she stays in the hospital. The chaplains came yesterday, but after they left the family became angry, thinking that the hospital was refusing to care for the patient any longer. We decide together, my resident and I, that helping support that patient and her family is the most important thing we can do today.

My resident schedules a meeting with the entire family. Young and old, male and female sit in a row on a bench by the patient’s bed. The way that he sits with them is impressive, and I learn volumes about culture and whole-person-care just by watching him. He sits down next to them. He acknowledges the fears and listens to the questions of each family member. He explains the situation much like we role-played earlier in the week, but of course it is more challenging for him in Chichewa, where there are no words for “stroke” or “oxygen.” He engages the family in a way that helps me better understand culture and support. “They know that I can’t directly say that she will die” he explains to me later, “but I because I use words that tell them everything indirectly, they understand what will happen.” He prays with them and then leaves them to discuss together what they will do. They ask to talk to the chaplain again. They clarify options and concerns with him later in the day.

The next day, he tells me that the patient passed. “The family appreciated it a lot. They were prepared.” I look forward to debriefing with him about the case. Will his experience here impact how he practices medicine and how he offers support, especially spiritual support, in the future? It’s a good thing Catherine and I are trading off supervision on the medical ward these days, because I definitely prefer teaching leadership, whole-person care, and systems-level medicine more than individual medical case management.

So I’m starting my thirteenth month at Nkhoma. I know I am still new here. But I feel a lifetime removed from those first weeks last year. Sure, this morning I had foot and stomach pain, but it’s not debilitating like the old days. It gives me an excuse to work from home a little and catch up on upgrading my medical education through online modules. “I had boundaries” “A nice day” and “could get used to this” mark my journal entries these days, though I’d be lying if I didn’t divulge the intermittent “horribly hectic” and “ready to give up. Again.” Things aren’t perfect. Patients still die and I still struggle with my role here and what can be changed and where there is no hope.

A Year in Review: September Update

As Chisale, the Medical Ward charge nurse left my office, I look at the paper we have drafted together, and I realize what a year this has been.  The Secretary of Health and Population is coming in two days to follow up on accreditation and quality improvement in Nkhoma Mission Hospital, so I worked together with Medical Ward leadership to list our projects and outcomes.  Each meeting and improvement measure didn’t seem like much at the time, and sometimes it felt like we slid back for every improvement we made. But now I hold in my had a paper with seventy lines of items – seventy! – which list improvements we have initiated, implemented, and sustained in the department over the last year.

First were the changes in clinician and nursing notes.  We must have had twenty different versions of these notes as we tried new formats and received feedback.  Some of the changes were little – pre-set spaces for writing patient pain levels, improvements in condition, and consent to treatment. Other interventions were bigger, like separating out the space for the problem list (what we see wrong with the patient) from the diagnosis (what is causing the problem, what we can treat).  The charts that the Medical Ward team designed last year are now being used in wards throughout the hospital, and we are continuing to revise our versions. The new chart formats are already helping us improve at least ten items necessary for accreditation, not to mention helping the staff identify patient problems and improve outcomes for patients.  

And the charts were just the beginning.  We identified improvements in infection prevention, emergency care, information sharing, analysis of adverse events, protocols, training, patient education, outpatient chronic disease management, and (most recently thanks to COVID) isolation room capacity.  Seeing every project listed one by one really hit me with the cumulative impact from this last year.  The nurses reminded me of projects I forgot or thought were abandoned but in actuality continued to make a difference.  I wondered how many of these intentional improvements had contributed to the reduced mortality rates on the ward that we have been observing over the last year.  I worked with Chisale to prepare a power point presentation of some of the more interesting projects and improvements, just in case he is called upon to showcase improvement projects for the upcoming Ministry visit.  It was such a blessing to see how a year of projects lead to impactful, lasting change.

In addition to my work in the hospital and Greg’s work teaching in Bible colleges, this next year we plan to be more involved in community-based training initiatives to benefit pastors and their communities. Greg is looking into pairing agricultural trainings with theological education to help pastors lead their communities towards wellness. I plan to come alongside with screenings and public health and diet teachings, based on priorities and interests of the churches.  We’re looking forward to how these programs might extend our impact outside the walls of hospitals and colleges.

Thank you for your continued encouragement and support, Greg and Christina

Roses

Of all flowers, roses have the greatest potential to make me happy. Maybe it’s because my mother curated incredible roses in her garden and used them as gifts to bless others as gifts. Between their look and smell and classic elegance, to me they really represent an ideal for gifts, for flowers on my table, and for plants in my garden. But the problem is, unlike my mother with her well-groomed plants and my sister who decorates entire weddings with hand-selected blooms, I have no talent for gardening. I was so excited that things seemed to grow well in Malawi, and I even hired a gardener to help me when I first planted seven rose bushes at our first home here. My bushes bloomed for a season and then started to wither. The four bushes I planted at my neighbor’s house grew much more aggressively than ours right next door, yielding copious lovely blooms. I asked Suzi once why her roses, which I planted myself and had no gardener, were growing so well. She told me that she spoke encouraging words to the plant daily. I tried that to my bushes. I also tried fertilizer and all techniques handed to me from master-gardeners I knew. The plants continued to wither. Maybe it was a nearby tree or ant hill which was choking them out. When Greg and I left that first house, that first clinic in Malawi, I dug up half of my bushes and gave them to my friend who was better at gardening. I hoped it could bless her.

When we returned to Malawi, I found that those remaining bushes, which had been without gardener or water, were blooming just fine. It was almost enough to make me give up on roses in the future. But not quite, because I really love the flowers, I see them as the epitome of gardening. So I was thrilled when I realized that there were twelve bushes in my new backyard in Nkhoma. There was even a small red tea rose blooming on one of the bushes when I discovered it. I hired a gardener and together we weeded, watered, pruned and fertilized. The bushes didn’t grow a single bloom for the next eight months. I bought ten more bushes, all of them with beautiful and fragrant roses when they were planted. Not one of them bore roses since. My friend, a nurse who can grow roses from clippings from bushes, advised me how to care for the plants, and I did my best. But every time I watered and examined my plants, I was discouraged that there had not been a single bloom since I moved in or since the new bushes were planted. I saw roses at other houses in our village, at my fiend’s houses in town, and at lodges when we traveled. I couldn’t help asking myself what was wrong with my garden, and my rose growing ability. I knew there were plenty of other beautiful flowers in my garden, some growing like weeds in the lawn and others springing up unsolicited in pots just from a little water. Even the pea plants my gardener started growing were with flower. I was wondering whether it was time to give up on roses. I like them the most and I really tried hard, but maybe there was just something about me, or my new environment.

At the time, things had been hard in the hospital too. A lot of the things which had caused us to choose this place had not materialized. I was keeping busy and helping others and enjoying work and life outside of work, but in the back of my mind, I felt like my life reflected my garden. There was plenty of growth, but not the one thing my heart craved, nothing from what I was most invested in or working towards. I wondered if it was a sign, that more effort was not going to yield the results I wanted, and I either had to be happy with the results that I could get, or more on to somewhere where there was already the impact I craved.

And then last weekend I saw it, the beginning of a pink, fragrant bud on the climbing plant in the corner. There were two more on the way. I know it’s not much, especially when I have almost two dozen bushes and a gardener, but it really meant something. Maybe there is a chance that I can have roses in my own garden. Maybe this doesn’t have to be a symbol of bareness in my ministry here or compromise in my mission after all. Of course it sounds silly when I extrapolate it that directly. But I do really like roses. And perhaps I get discouraged a bit easily when I can’t reach a goal.