Following Fifi

by John Crocker

  I was humbled by the fact that Hamisi chose those particular characteristics to appreciate. During the interview, Hamisi told Abdul he was a bit nervous answering the questions, perhaps because he knew his responses might be included in a book, but Abdul and Hamisi still managed to produce five pages of insightful writing that I received in Seattle with great appreciation.

  The path continues for Hamisi and me today as we live our very different yet interwoven lives far away from each other. Now we have met some of each other’s children after having shared a unique adventure as young men starting out in life. If our strong bond and memories of each other could last thirty-six years, I’m certain they will keep us connected for the rest of our lives.

  CHAPTER TWENTY

  MORE FOREST REFLECTIONS: BROADENING MY PERSPECTIVE ON FAMILY MEDICINE

  After passing over the mountain range for a second time that day, I stopped talking. I was too exhausted to both speak and carry on walking. My legs were growing weak and I felt short of breath as we began our descent. Eventually I noticed that my hiking companions had grown quiet too. The heat lifted the rich, earthy smells of dry grass and ancient soil. We could hear the late-afternoon baboon grunts, pant-hoots from chimps in the distance, and our own heavy breathing as we made our way toward camp.

  I kept thinking about one of the older villagers who had approached me at Hamisi’s house. He was a stranger to me, probably one of Hamisi’s relatives, and he had slowly limped up to me. He had a weathered face and a wiry build, and wore a thin blanket wrapped around him. He looked into my eyes, and with a kind and confident voice, said in Swahili, “Can you get me some pain pills for my arthritis?” He was referring to his hip. Apparently the local liniments he used were not effective for this degree of pain, due to what I assumed was a worn-out hip joint.

  Walking along and looking at the peaceful, golden countryside, I couldn’t help but contrast Hamisi’s life as a field assistant and medicinal plant specialist with mine as a doctor in a bustling American metropolis, as well as compare the kinds of medical care available in each of our communities. There’s a huge gap between a Tanzanian man asking for pain pills and the world of Western medicine, where he would have simply been offered a hip replacement for his advanced arthritic condition. The man’s life might have been quite different if he had had a new hip—and my life might have been different had I chosen to provide health care to an African village. There are so many ways to improve the quality of human life—from the most cutting edge of life-saving medical interventions to the simplicity of relieving pain. In a perfect world, a health care provider could improve life wherever he or she encounters it.

  I suddenly thought I might have been more satisfied as a Tanzanian medicine man than as a Western doctor. After hearing about Hamisi’s personal losses as well as the many other health issues in Africa, I found myself wondering what would have happened if I’d returned to Tanzania to work after completing my medical training instead of staying in the United States. Would I have been more fulfilled working in Africa? Would I have done more good there than in a country with many doctors? These thoughts preoccupied me as Tommy and I hiked with Abdul and Rudo back to Gombe from Bubongo Village.

  For as long as I can remember, I’ve been attracted to cultures different than my own. Perhaps I was searching for more inclusive and accepting social environments that would accommodate my shy and unaggressive nature. Whatever the reason, I continue to enjoy learning about other cultures. In particular, I’m drawn to learning about cross-cultural health beliefs and spiritual practices that influence people’s lives across the globe. It’s been especially enjoyable to see how my boys adapted in diverse settings as Wendy and I made choices that introduced them to different cultures. This included our trip to Gombe as well as a two-month stint the family spent in Barbuda, near Antigua, where I practiced medicine in a setting that reminded me of some of the towns in Tanzania. I also brought my family along when I signed up to serve as the ship physician for Semester at Sea, a seagoing university for 750 college students, which exposed our boys to Indian orphanages and Cuban medical centers, among other interesting sights in the four-month voyage around the world. These trips broadened my children’s perspectives, but also helped me expand my view of what it means to practice medicine in diverse communities.

  The Highs and Lows of Modern-Day Family Medicine

  Throughout my long career in family medicine I’ve had definite highs and equally definite lows. Mid-career, my health care organization implemented electronic medical records and also increased the number of patients in our practices considerably. So began the dark years. It didn’t help that I was experiencing sciatic nerve pain in my leg from repetitive trauma to my back from playing league soccer in my midforties. Sitting was difficult. Though this should have given me more empathy with my patients’ aches and pains, at times I felt like saying, “You think you have pain!”

  A period of five frustrating years resulted for most of us in family practice including primary care physicians, physician assistants, and nurse practitioners across the country as demands rose and resources didn’t. Twelve hour days of relentless concentration on patient care took over our lives; I had to learn the new computer system, email patients, and perform other virtual visits such as phone appointments, in addition to seeing twenty-two patients a day. Applications for residency positions in family medicine plummeted because of the unsustainable workload throughout the field of primary care.

  I remember sitting at my computer one evening at eleven P.M., reading an email from a patient. This was after a busy day seeing patients from 8:00 A.M. to 6:00 P.M. I had just completed looking at twenty lab results and responding to six nursing questions about advice for patients.

  My brain was clogged with too much information as I read my patient’s message about headaches that started near her left ear, then radiated to the top of her head, followed by a buzzing sound and possibly decreased hearing on the left. She mentioned that her jaw was also bothering her. The headaches had been going on for a week, and she wanted to know what I suggested. Headaches such as she described can be due to stress or tension, but they can also be due to a brain tumor called an acoustic neuroma, or perhaps temporal arteritis, which if not promptly treated causes blindness.

  I stared blankly at the email for five minutes. We call this “brain freeze.” I was too tired to think or get angry with my computer, my superiors, or the world, so I turned and gazed at the photo of Bubongo Village on the wall and the picture of several chimps feeding on milk apples as I tried to escape the reality on my computer screen. As I looked at the images, I felt a familiar sense of grounding and calm flow down my neck, which helped reenergize me.

  When I did come back to the task at hand, I had enough focus to make a clinical decision and type it as an email to my patient. The next day I was relieved to discover that the woman had neither of the serious disorders.

  I began to toy with the idea of leaving the practice because of the stress it was placing on my family and me. My anger with the untenable workload was building. A big frustration even today is how my colleagues and I care about the people we treat and are willing to go the extra mile for them, but at the end of the day, many of us are burned out. We’ve lost some of the joy and energy necessary to feel good about our work and about ourselves. We trained to be healers as well as clinicians, and modern medical care doesn’t always value this distinction. There’s little breathing room or processing time during a typical day unless you give up the time it takes to really connect with patients and simply respond, like a computer, with mechanical input and output—and that is not doctoring in a human or healing way.

  Then came the “medical home,” which allows more time with patients for each visit and time for emailing and phoning them about their health problems. A collaborative approach to diabetes, heart disease, and other chronic conditions by nurses, pharmacists, medical assistants, physician assistants, nurse practitioners, and family physicians
with individualized care plans resulted in better outcomes for patients. We hired more physicians to allow for manageable practice sizes. The days are still long, and most of us email our patients from home, but the hectic pace has been reduced, as a portion of our computer work has also been delegated more appropriately to nursing staff.

  Along with my complaints, I should acknowledge the bigger picture regarding medical care worldwide. The one doctor to twenty-six hundred patients in my practice during the dark years might have seemed overwhelming, but not compared to the one doctor for fifteen thousand patients in areas of northeast Africa and many other parts of the world. A family doctor I know from college days recently described his experience in Dar es Salaam; he would see up to two hundred patients a day in a clinic there, working with six medical assistants and two nurses as support staff. He had time only to hear patients’ brief history and then to treat their infections or injuries with speedy efficiency.

  Compensating for some of the frustrations and long hours in family medicine is the joy in delivering babies. This process is rewarding and usually exciting, though we always hope not too exciting. I chose not to continue the obstetrical part of my practice eight years ago, but I felt great satisfaction delivering babies and growing closer to the families as we spent hours together during the labor and delivery.

  I’ll always remember the delivery of a newborn whose two siblings watched the birth. In my practice, I tried to accommodate special requests of parents for the births of their children and approved the presence of this couple’s three-year-old son and five-year-old daughter in the birthing room.

  Though the children were very young, the parents were prepared to explain things as they went along. The birthing room was large and comfortable—though being in labor is never comfortable—with a rocking chair and Jacuzzi. This mother was a pro at this point, having gone through labor twice before. Her labor went fast, and as the baby’s head began to emerge, everyone gathered close to see the new arrival. After the head eased out, there seemed to be a halt; the body didn’t follow as expected. One of the most stressful emergencies in childbirth is a shoulder dystocia, in which the shoulders hold up the delivery. If the infant is not delivered within a few minutes, the brain can be deprived of oxygen, leading to brain damage or even death.

  As I applied traction to the head, the nurse applied firm pressure on the mother’s lower abdomen above the pubic bone to push the infant’s shoulder down into the birth canal. I had no idea what the siblings were thinking, but when I glanced up at them, they both looked bored. Luckily, they had no clue as to the seriousness of the situation. I calmly but determinedly asked an attendant to page the obstetrician on call STAT. I continued to use a calm voice, though my face was flushed and my heart racing as I reached in to adjust the position of the baby. This finally allowed the big guy to get unstuck and emerge.

  After a brief pause, the infant cried; then the mom started crying, and then the dad. The couple embraced as the baby, looking strong and healthy, nestled into his mom’s breast.

  The oldest child said, “That was cool.” This was her only comment after the dramatic, nearly heart-stopping delivery.

  Both children came over to look at their new brother as I attended to the placenta and my tension eased. I think the kids held up much better than the adults in the delivery room had and likely benefited from seeing the birth, which had been demystified in a way by their inclusion in the process.

  As my time with the chimps connected me closely with the family life of the mother-infant pairs I studied, delivering babies in my practice allowed me to feel a similar closeness to the family dynamics of my obstetrical patients and their families while they toiled through labor and happily welcomed the new member into their family. For me, there was down time—sometimes lots—to ponder life and take in all the emotions that were flying around the delivery setting. And there was no set schedule to follow, just Mother Nature. Thank goodness!

  The Turbulent Teens

  It was a bad joke: “Looks like I’ll have time to get caught up with paperwork this afternoon,” my colleague blurted out to me early in my career. “I have two teen exams in a row.” The somewhat humorous but very poignant comment referred to the fact that teenagers in general don’t reveal much or talk much during the exam. The aloof gaze, the dangling hair over the eyes sometimes hiding acne, and the brief answers—all common features of the teenage exam. Parents were of course politely asked to leave the room for a short time so that these developing adults could unleash their opinions about their parents and reveal other secrets in a confidential setting.

  Despite the almost comical difficulty involved in getting a good history from teens, I eventually enjoyed learning about and even delving into this scary area of development. After all, I had seen my boys traverse this phase of life, walked through it with my earlier patients, and witnessed the tumultuous time in adolescent chimps when I was a student at Gombe.

  I became curious about the purpose of this volatile period of life in terms of human and nonhuman-primate survival. Accompanied by the impulsive and sometimes high-risk behavior of teens, there is an important “plasticity” of the brain from puberty to the end of adolescence; plasticity refers to the brain’s ability to change and adapt to the specific environment in which we are raised. This ability of the brain to adapt, learn, and even physically change during adolescence was likely crucial to humans’ ability to adapt to highly variable environments throughout our history. Because of a less sophisticated cerebral cortex in chimps, their plasticity is not as strong as ours during the teen years, and yet it’s still important. Both species are programmed to leave or detach from their caretakers and are attracted to novel and exciting situations.

  As I attempted to reach the hearts of my teen patients and my own boys during this stage of development, I really had to summon my mantra, Remember Fifi, a lot of the time. Her never-ending patience with energetic and sometimes wild Freud stayed glued in my mind. In the end, Freud turned out fine and continued to have a close bond with his mother. And it really does take a village in some teens to manage this stage in our current electronic world of cell phones and computers. From DBT (dialectic behavioral therapy) groups for kids in need of peer support to total hands-off treatment for the high achievers, there is always hope that by age twenty-five, when the human brain is fully mature (twenty-two in females), there will be a return to a normal and more peaceful existence. I am hopeful that more emphasis on adolescent health will result in better outcomes for teens in our society and throughout the world.

  Lessons from Traditional Healing

  Just as in Western countries, medicine in Tanzania has evolved with changing demands, but many people still view the traditional village medicine man as an important health care provider. When I was a student at Gombe, the local medicine included strong elements of holistic care. People living in rural villages were most comfortable with very personal, individualized care from a medicine man, and were willing to pay a fee for this service even though there were free government clinics in most nearby cities. This tradition continues today, though not to the same degree.

  Recently, I came across an article I had saved from the April 1974 issue of Hospital Practice that summarized health care in Tanzania at that time. A quote describing a typical patient caught my eye: “He is likely to object to a crisp treatment of his symptoms, when he has been accustomed to the holistic approach of the medicine man for whom the patient exists as an entity with no clear demarcation between psyche and soma [mind and body].”

  The patient’s social surroundings and even the spirits of those in the community who have died are considered. Treatment often includes herbs and other plants from the environment. As the healer assesses the patient’s problem, he continually looks for feedback from the patient as he takes a history and begins to give advice for the problem during this initial assessment. If the patient feels that the healer is off track, the healer graciously refers him or her to anot
her healer.

  Early in my practice, just after completing residency, I offered counseling sessions to patients enduring difficult times. A female therapist and I met with couples having relationship problems to give them support. I enjoyed having thirty-minute appointments to delve into their marital lives as we learned about their specific issues. As we offered advice, we also tried to model good communication between the two of us performing the counseling. This opportunity soon went by the wayside as demands for more regular fifteen-minute office visits took priority. I missed this deeper connection with couples, a holistic approach that recalled the kind of traditional healing I had seen in Tanzania, where all aspects of people’s lives are considered in their treatment.

  Over the years, I’ve also found it fascinating and instructive to tease out a patient’s own view of his or her health challenge. One of my senior instructors in medicine taught me this early on. During one rushed clinic day as a resident, I hurried to this preceptor’s office and presented my required history and assessment of a young man with a sore throat whom I had just examined.

  The preceptor, as usual, said, “What does the patient think is going on?”

  I refrained from saying, “It’s a simple sore throat! Why do we need to know what the patient thinks is going on?”

  Instead I went back to the exam room and asked the patient what he thought was causing his sore throat. He immediately opened up about his fears after having engaged in oral sex for the first time and voiced that he wondered if the throat pain was related to this. He was clearly anxious in general about the encounter and thought he might have contracted a serious disease, but he wasn’t able to bring up his concerns without my directed questions. I learned a lot from this and—I hope—helped the patient, who would have gone home still worried, his concerns not aired, if I had not invited him to share them. I could hear his sigh of relief as I explained the low likelihood of any serious health consequence in his situation, and I did a throat culture for further reassurance.