careers

it seems all my posts are somehow related to the work i'm doing in zambia, and this one will be no different.

i was seeing a patient yesterday who was chronically wasted and anemic from HIV yesterday, and today when we went to check on him, we found out that he had passed away during the night. what we couldn't really figure out was WHY he died - he was wasted, but not that wasted... anemic, but not that anemic... he did have TB, but had no pulmonary symptoms.... at any rate, it seems that many of the deaths happen for some reason that is not entirely explicable. the fellow was also quite young - only 31.

later on, we were rounding (basically checking up on the patients we were responsible for) and encountered a young lady with dilated cardiomyopathy (DCM) leading to refractory (that is, untreatable) heart failure. yet another depressing case... there is so much DCM here, largely due to HIV; in class we learned the number one cause of DCM is idiopathic, meaning the exact etiology is unknown, but what often happens is that the DCM is associated with viral infection. with the advent of HIV, all the viral-associated idiopathic pathologies are far more common, such as DCM, and also a rare condition called guillain-barre syndrome (GBS), a polyneuritis that causes ascending paralysis and possibly fatal respiratory failure.

it is sad that so many of our patients have terminal conditions at such a young age. internal medicine in the western world is defined, more-or-less, by chronic disease affecting the elderly who have hopefully led fulfilling lives. it is just so sad. and the patients i see are certainly amongst the well-to-do. in rural areas, where the majority of the people live, things are probably far, far worse

the more i work here (and i haven't worked here long), the more convinced i am that working in policy is the way to go. it is good to be a physician in low-resource settings, but a physician can only see so many patients in a day, a year, and even a lifetime. perhaps its obvious, but it seems that working at a policy-level, either by recruiting more resources to help or by engaging these resource more efficiecntly, is a far more effective way of effecting change. but as always, it's hard to figure out the best way to go about working in policy. for the past few years, i've thought that i should go into internal, go into infectious diseases, work a few years, and then get a masters in public health. by the time all that is done, i would probably be 40 or something. now, i wonder if i shouldn't just go into community health, where they teach you policy (albeit policy as applied in a developed setting) throughout the 5-year residency and you get the MPH during your training. i also wonder if i should try and do more research (i.e. get a PhD) - something that is interesting and that can make you quite an expert in a particular area, but again takes avery long time

who knows, who knows