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.