Final Paper

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A Heart for the Work: Journeys Through an African

Medical School

- Chapter 5-

Today’s Outline

1. Missing Resources & Compromise

3. Consequences: Losing Faith

The Clinical Crisis

2. “Medical Tourists” & “Real Medicine”

Overview • The next step on these students’ journey is learning to

diagnose and care for real patients (the “clinical years”).

• Wendland found that this stage in their medical education was characterized by a marked change in their relationship toward practicing medicine.

“In their clinical years, students’ narrations of their experiences changed sharply. The pride and exhilaration so evident in the recounting of basic science students ebbed; pain and anger took their place. Neither change was invariant, but both were common and striking. The conditions students faced on the wards prompted a rise in negative feelings about their work and new doubts about their healing potential, contributing to what I will call a ‘clinical crisis’” (120).

Remember this?

“The students (…) enthusiasm for the science of medicine was palpable in these interviews, and they eagerly anticipated the opportunity to put their scientific theory into medical practice as their training continued.” (115)

Missing Resources & Compromise

Missing Resources • When they began experiencing what it is actually like to try to

care for patients at Queens Hospital, the students Wendland studied were quickly overwhelmed by the absence of:

1. Medical supplies and equipment

2. Staff

• These absences was perceived in the light of the expectations that students had for practicing medicine. These came both from their technical textbooks, but also from the sense that doctors truly had the power to help people.

Missing Resources Medical supplies and equipment

“At times, barely adequate equipment could be patchworked together from donors,

government stores, and various multinational research projects. (…) At other times, the

hospital was without soap, water, ‘plaster’ (surgical tape) and gauze” (121).

Missing Resources Staff

“The student-doctor assigned to a medical, surgical, or pediatrics ward in a public hospital (…) typically faced sixty to a hundred patients daily, some with relatively minor illnesses and

most with very serious ones” (122).

Missing Resources “An ethical and emotional crisis engulfed many trainees when they reached these wards and encountered their first living patients, when the professional identity and expectations they had taken on during preclinical education came up against the realities of patient suffering and physician helplessness in this extraordinarily resource- poor setting” (123).

“Lacking access to many of the medical tools and technologies their textbooks assumed would be available, faced with the realities of risk, poverty, and an apparently endless workload, they struggled with this transition in ways that ultimately forced many to reevaluate their roles as doctors.” (124).*

* Note Wendland’s comparison of the metaphors clinical students of the Global North used (“going into battle”) vs. those Malawian students used (“the deep end,”“the forest”.)

Missing Resources & Compromise

• Wendland claims that, faced with these conditions, these student-doctors typically made compromises. That is, they did not do exactly what they had been taught to do or exactly what they thought they should do.

“With limited time and limited space, clinical students began to make compromises with which they felt deeply uncomfortable.” (124).

• She found that pre-clinical students “often expressed pride”(125) about their ability to manage a heavy workload. During the clinical years, this turned to talking about compromise.

Missing Resources & Compromise

• Wendland claims that it was not just the missing resources, but the compromising itself that was so “dehumanizing” for these students (125).

“Students and interns agreed that it was impossible to do an adequate job under these circumstances, but they felt they had no other choice” (126).

• Students at this stage talked not being “‘able to apply all the ethics that we are supposed to apply’” (125) and about “losing your human face’” (126).

Missing Resources & Compromise • These compromises were extremely painful and soul-crushing

for these doctors:

- They had been trained with textbooks that assumed particular resources (which the students frequently mentioned [131])

- Many of them had become doctors to “heal Malawi,” to truly help their countrypeople escape suffering.

-Their compromises left many of their patients dead, and few healed (e.g, p.131)

• Students expressed the feeling that their hard work had been for nothing: “‘at the end of the day, people still die’” (132).

Missing Resources & Compromise

“For most members of the class, it seemed to be the experience of their own powerlessness in the face of medical need and systemwide breakdown that was

demoralizing. They were already aware of the magnitude of poverty and suffering in their country, but where not used to facing it as those charged to heal yet unable to

do so.” (132).

“Medical Tourists” &

“Real Medicine”

Medical Tourists (133-135) • Foreign doctors and medical students coming for short-term

stints were a significant part of the medical staff working alongside the Malawian student-doctors. They were “health care providers and trainees eager to see how medicine was practiced in parts of the world far from home” (133).

• All of the “medical tourists” that Wendland knew were white, and none of them were from Africa.

• Wendland argues that having these “medical tourists” around in the hospital contributed significantly to the student-doctors relationship to and experience of practicing medicine— and to what “real medicine” was (134).

Medical Tourists

• The presence of these white clinicians from richer countries reinforced the sense among the Malawian student-doctors that the practice of medicine in Malawi was “less-than.”

“Real Medicine”

• The medical tourists had been trained using the same textbooks, but they practiced medicine in a world where the textbooks actually fit with the possibilities the clinicians had at their disposal.

• “Encounters with medical tourists (…) could reinforce a sense that real medicine was what happened elsewhere” (135).

Medical Tourists “Real Medicine”

“In the case of medical tourism in Malawi, it was the visitor who was assumed to be the authentic representative of global biomedicine. Malawian medical students and their fellow Africans became the marked impoverished Other, while visiting Northern students and physicians became unmarked global doctors (134).

“…From there, it was a short step to seeing real medicine as a necessarily expensive and high-technology endeavor, and Malawian medicine as somehow less than real, or second- rate” (135).

Medical Tourists “Real Medicine”

Notice how this process:

• Contributes to the student-doctors’ sense of the futility of their work.

• Reproduces the values attached to biomedicine in the Global North (more technology as better).

• Reproduces the perspective represented in the social science literature that biomedicine belongs in the Global North, and that the practice of biomedicine in other regions of the world is a kind of “alternative” or “variant.”

Consequences: Losing Faith

Consequences: Losing Faith

Wendland reports that during this difficult period of their medical training, the students lose faith in:

• God

• Medicine

• Their government

Consequences: Losing Faith

• Wendland did not have any medical students speak to her directly about losing faith in (the Christian) God. However, her data show a distinct difference in how much students talked about God in the early years vs. the clinical years.

in God (137-138)

• In the pre-clinical years, students talked about God playing an active role in the therapeutic efficacy of medicine: that a good doctor is a good doctor in part because God is working with her to heal.

• During that earlier stage, they also discussed “faith as sustaining” (137) them through the difficult times they would face as doctors.

Consequences: Losing Faith in God

“[T]here is some evidence that the clinical transition diminished student certainty about the medical utility of faith, if not faith itself. Clinical students no longer spoke about God the consultant or about prayer as the key to surgical success, never described good doctors they knew in terms of religious faith, and never discussed spiritual counseling with patients. On questionnaires, they were much less likely to believe that a strong spiritual life made a better doctor” (138).*

* Wendland interprets this lack of mentions God in their responses to indicate the social sanctioning against directly proclaiming losing one’s faith in God in a recorded interview/ questionnaire.

Consequences: Losing Faith in the government (138-142)

• During this period of medical training, Wendland documented a growing negative attitude toward the government that was seen as deliberately neglecting “the facilities, patients and workers” (138).

• That is, they came to see the Malawian government as one of the primary causes of the horrible, dehumanizing circumstances they were living through every day.

• This shift was in a complex relationship to what had been their feeling of becoming “true Malawians” with a desire to “heal Malawi.”

Consequences: Losing Faith in the government

“They came to believe that Malawi’s politicians were out of touch, hypocritical, and uncaring” (138).

“They frequently reported that they felt a lack of respect and commitment from the government, (…) and described themselves as ‘disillusioned’ or ‘disgusted’” (139).

“Widespread resentment of government failure surfaced (…) Malawians’ sense of anger and betrayal was palpable” (139).

Consequences: Losing Faith in the government

• These sentiments were aimed in large part toward the “waste of money that resulted from corrupt practices” (139).

• Governmental corruption caused the resources that the hospitals needed (staff, medical supplies, money) to be diverted (buying votes, shifting resources toward “favored constituencies or patients” [140]).

• Wendland points out, however, that Malawi’s health sector troubles are also deeply tied to international, macroeconomic forces that were set in motion in the postindependence era (putting Malawi in a huge amount of debt).

Consequences: Losing Faith in medicine (142-147)

• Wendland argues that during this period, the students “started to lose faith in medicine — as a career and as a force for good” (142).

• They became “disenchanted” with the salary, the workload, and the working conditions (143), and showed less enthusiasm in terms of recommending the profession to others.

• They also had repeated experiences with absent doctors (mostly consultants) who seemed to never be available when they were needed.

Consequences: Losing Faith in medicine

• Wendland identities a large cause of this loss of faith to be the common traumatic experience of being left with patients who needed urgent care, but who the student did not have the ability to care for without help from a superior.

“[N]early all clinical students and interns had experienced the terror of facing a true emergency alone and unprepared. The impact of these experiences was devastating, and felt beyond the individual” (146).

• This connects to the growing frustration with the lack of resources and staff, and with government neglect.

Conclusion • Wendland is going to go on to argue that this clinical crisis

was actually productive for these new doctors.

“I will argue in the pages ahead that these feelings gave them access to an understanding of the social and political forces underlying their patients’ illnesses and deaths. Northern students at this point in training learn to experience their own emotional responses as distractions, as threats to the practice of scientific medicine. For these Malawian students, such responses did not seem to be perceived as distractions. Their emotions were doing ethical work. They were neither threats to objectivity nor threats to a real understanding of what was happening; instead, they were in some cases the mechanisms by which that understanding happened” (147-148).*

* Note Wendland’s finding that clinical work did not force students to exclude the social causes of their patients’ conditions (127).