This is the hardest post to write, because I feel like somehow I need to bring it all together and make sense of my experience. I'm probably being way too hard on myself, but the urge is there.
Overall, it was a wonderful experience, made wonderful by my Bhutanese friends and colleagues, and by the other HVO volunteers. I could not have asked for better apartment mates, dinner companions, and fellow philosophers. My Bhutanese colleagues were smart, hard working, and eager to learn as well as being incredibly gracious hosts. Were there flies in the honey? Of course. As some of you have heard me say already, the blog has been sanitized to protect the guilty. There was some care that was far from perfect and there were a couple of people floating around who were a bit harder to endure and I didn't like the trash everywhere, but those topics are for private conversations. I'm not complaining, but it is important to me that readers understand that I was aware of the less good and was not walking around starry-eyed. Overall, it was a terrific experience and I very much want to go back and work in Bhutan again.
So, I guess the questions I need to answer is what did I learn and did I help promote positive change?
What did I learn?
North Americans are incredibly lucky. Our material wealth is obvious, although I'm not sure that it creates as much happiness as we would like to believe. However, trappings of prosperity like central heating, potable tap water, and good roads make life more pleasant and should not be taken for granted. It takes the contrast of living in Thimphu to see that clearly. What we don't realize we have is freedom and democracy. Now, I know that sounds corny. Anyone who knows me is well aware that I'm not a flag waver. However, we take for granted that we can speak freely, make suggestions, challenge authority, try something new, and demand change when things are not working as they should. This is the real gift of freedom. Growing up in a culture where acting freely is taken for granted creates innovation and progress, and we are the beneficiaries of that culture. Democracy is new to the Bhutanese. They are learning how to use it, how to speak up, how to try new things, and not settle for the status quo when the status quo is not good. Hopefully they will learn to take the good of our system and maintain the graciousness and outlook of classical Bhutan. I think they will.
The second thing that became evident to me was how we take infrastructure for granted. I was given the opportunity to give a lecture on what could change in the ICU. I did so, being polite and respectful but direct. My pitch was about infrastructure. I had framed it in terms of predictability and consistency, but it really comes down to the same thing. A working infrastructure means that when you flip the switch, you don't wonder if the lights will come on, you assume that they will. In medicine, infrastructure is not only about a physical infrastructure, but an infrastructure of ideas, assumptions, and systems. You can use a blood gas analyzer because there is a system in place to make sure that reagents are always on hand. You can use a ventilator because there is a system in place to make sure that there are spare parts available. You can care for a very sick patient because you know that certain medications will all be available. When global health experts talk about sustainability, it's another way of saying that the host country has created an infrastructure of ideas, things, and systems so that the process functions independently of any one person. Sustainability and creation of an infrastructure is a consequence of widespread acceptance of the new idea or process; key players have decided that the work of creating and sustaining the infrastructure is outweighed by the benefits bestowed by the new system. I think that needs assessment is a huge piece of change, but that we need to understand what leads to sustainability and creation of infrastructure and apply those ideas vigorously. The flip side of that is that much of what makes American medicine so effective is not cutting edge technology, but that infrastructure of things, ideas, and assumptions that makes a supply chain work and that puts the right patient in the right operating room with the right surgeon who is going to do the right operation with the right instruments.
I think those two ideas were my two big philosophical takeaways. There were a bunch of other things too. I greatly missed my wife, confirming that after thirty years I am still crazy about her. At the same time, I was able to function socially without her present, which was reassuring. I'm lousy at social situations, and needing to go it alone for a month was hard but healthy. I have always known that I am adaptable; that was confirmed with the ease with which I slipped into life in Thimphu and how I tried to cobble together treatment plans when my usual meds and tools were not available. By contrast, I saw another view of our medical care system: big, bloated, hyper-regulated, over-funded and not always functioning in the patients' best interests. The only problem I have is that I have no idea of what to do with that observation. I got to live for a month in a country whose chief concern was Gross National Happiness rather than Gross National Product. I learned that Gross National Happiness was not about everyone walking around giggling, but that the collective welfare, the collective prosperity, and collective health of the citizenry was every bit as important (if not more so) than any one individual or group. I got to live in a place with an entirely different aesthetic, and I loved it. I spent time with wonderful, gracious people who were more than willing to share what they had with me. That was worth the trip in itself.
What did I leave? Well, to be honest I'm not sure. I'd love to know if the nurses quietly removed the chart dividers the day after I left. I hope not. That seemed to be an easy win. I know I got my message across about ventilator management, and I think I got my message across about fluid management. Antibiotic choice and use-- not as sure about that. We did get physical therapy into the ICU, which I think will be sustained. That will be a good thing. I was involved in the first discussions about better ICU training, and I hope that the docs and Ministry of Health can get some training slots for the docs. My anesthesiologist and internal medicine colleagues wrote a letter to the ministry complaining about drug shortages. I was not directly responsible for this, but I like to think that maybe my willingness to speak up about the problem and not simply accept the status quo played some role in facilitating that complaint. I talked repeatedly about reliability and consistency and how it was equally important to have a steady supply of spare parts and reagents as to buy the machine in the first place. I hope that got some traction. Finally, I said repeatedly that good ICU care was about being meticulous rather than having high tech. That's a disappointing thing to hear because toys are fun, but it is critical to success.
So, that about wraps it up. My 30 days in the spotlight are over. No more celebrity status as the American ICU doctor. Back with the computers, and meaningful use, and balky electronic medical records and my one day a week of sleep clinic. I hope this has been an interesting thread to follow. We'll pick up again when I go back...
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