The Foreign Service Journal, September 2010

34 F O R E I G N S E R V I C E J O U R N A L / S E P T E M B E R 2 0 1 0 forced me to expand my definition of being a clinician. While my U.S. colleagues might have a few co-workers or friends as patients, that categorizes all of my patients. It is an especially difficult responsibility to maintain medical objectivity alongside a personal relationship, but that’s what I do every day. And whenmedicine, which is more art than science, fails a patient, I know that I rethink, second-guess and ruminate far more than I did in my prior practice. One of my many responsibilities, using U.S. Depart- ment of Transportation guidelines, is to evaluate local em- ployees who drive embassy vehicles. Ninety percent of the drivers are men who are extremely worried that they won’t pass the medical examination and will be suspended from driving. Fortunately, that rarely happens. Hypertension is usually the biggest health issue that presents in these physicals and, regardless of the actual blood pressure reading, the drivers always blame it on “white coat syndrome.” Most of the time, the initial con- versation goes something like this: Me: I see your blood pressure is a little high today. Do you have high blood pressure? Driver: No, I’m just nervous to be here. Me: Really, there is no reason to be nervous. Do you take any prescription medication? Driver: No, unless my doctor gives me something. Me: Has your doctor given you anything recently? Driver: I have those little pills I take when I need to. Me: What are those pills for? Driver: For when I get stressed, like now, andmy blood pressure goes up, but I don’t have blood pressure problems unless I’m stressed. Me: How often do you take those pills? Driver: Well, my doctor toldme to take them every day, but I only take themwhen I’m stressed or I know I’m going to be nervous. Me: So, you are being treated for high blood pressure? Driver: Yes. Me: OK, now we are getting somewhere! Where the Personal Meets the Professional Practicing medicine in the Foreign Service is akin to working in a small town— a very small town. While a few embassy populations are quite large, with more than a thousand staff members and families, most are well below the 500 mark. I am responsible for the health needs of nearly 200 American employees and family members in Prague, plus the occupational health of about 100 local staff members. This means that my patients are also my colleagues and friends. It is not uncommon for me to have lunch or dinner with someone I treat in the clinic the same week. Rarely are my fellow health practitioners in a situation where we provide care for people we don’t see frequently outside of the health unit, even if it is just passing in a hallway. I have always had mixed feelings about this unusual en- vironment, because having such a close relationship with one’s patients has both advantages and disadvantages. Under this system, my feeling of responsibility is both pro- fessional and personal. My medical colleagues and I have to maintain clinical objectivity at the same time that we have a very special interest in the people we are treating. Recently, one of my patients became very ill, requiring advanced medical care within the Czech health system. I am thankful there is such competent care available in Prague, but the length and severity of the illness have caused me many nights of tossing and turning. I worry and wonder if all the people making decisions in this case — myself included — are making the right decisions. From the beginning, there has been a high chance of complications, and I am acutely aware that, if things don’t go well, my embassy colleagues might look at me with a critical eye. But that isn’t the cause of my fidgety sleep. I have tremendous regard for my patient, and it is that per- sonal connection that causes the angst. At my first post, I had to hospitalize a septic 3-year-old. The parents were on their initial overseas assignment and had been in country for exactly one month. The mother was a lovely young lady who was a good bit shorter than I. After the baby had been admitted to the hospital for the intravenous infusion of the drugs that were going to save her, the mother literally grabbedme by the shirt and pulled my face down to hers. “Don’t let my baby die!” she cried. That was the first time I felt the full force of the re- sponsibility this practice can bring. And it wasn’t the last. Fortunately, the child did well and left the hospital in less than a week, her mother having never left her side. The Foreign Service isn’t an easy lifestyle, but I enjoy a unique opportunity to experience medicine in a way not possible in the United States. I have been honored to know and work with some amazing medical practitioners in var- ious parts of the world, to see diseases that don’t exist at home and to collaborate closely with my MED colleagues. For me, the decision to join the Service was absolutely the right one. ■ F O C U S