Teleconferencing Medicine

Tues­day was one of my most reward­ing days in Afghanistan.  I wit­nessed some­thing unde­ni­ably and irre­versibly positive.

In the morn­ing an ambu­lance came to pick Dr. Pete and me up from the Taj.  We crammed along with the dri­ver in front, while 5 female OBGYN doc­tors and a male ward direc­tor sat in the back, occu­py­ing one bench and the patient cot.  I’ve rid­den in the back of this ambu­lance before and know that the cot slides around and the whole set­up can’t real­ly accom­mo­date more than 3 com­fort­ably. But the back also con­tained a bunch of endoscopy equip­ment, which I had tak­en out of the hos­pi­tal (where it had pre­vi­ous­ly sat for 7 years unused, after USAID proud­ly donat­ed it but for­got to teach any­one how to use it, or even both­er to fig­ure out whether sen­si­tive expen­sive equip­ment from Amer­i­ca can be plugged into the unpre­dictable cur­rent com­ing out of their wall sockets.)

Then again, I have also rid­den on the lap of an old­er beard­ed Afghan stranger in a Toy­ota Corol­la sta­tion wag­on taxi where we were 11 all togeth­er and 3 women sat in the trunk. Hameed, who was my com­pan­ion on this adven­ture, tried to pass me off for an Uzbek who did­n’t know the local lan­guage. That cov­er last­ed for about 3 sec­onds until one of the geezers start­ed talk­ing to me in Uzbek, and then laughed that I did­n’t know my own lan­guage. Then Hameed claimed I was mute, for lack of any­thing else to say. That excuse last­ed for as long as I did­n’t speak (3 sec­onds) since he had failed to warn me of his inten­tions. They all laughed and the guy told me ‘kine kana’ for sit dude and guid­ed me onto his lap.

Ambu­lances are not used in the same way in Afghanistan.  They may some­times trans­port a patient from a rur­al clin­ic to the main hos­pi­tal, but most­ly they are for off-label uses. The dri­ver is crazy even by Afghan stan­dards. Usu­al­ly he blares his siren, verves in traf­fic, as if he were born to be a race cum bumper car dri­ver, play­ing per­pet­u­al chick­en on the drag. Today he man­aged to keep him­self most­ly in check, prob­a­bly because of the female doctors.

Today, we were head­ing to the ILC (the Inter­net Learn­ing Cen­ter) at Nan­ga­har Uni­ver­si­ty for the first ever tele­con­fer­ence between the doc­tors of Afghanistan and Pak­istan, and I was a lit­tle bit anxious.

Cul­tur­al­ly, we men are not allowed to speak to the female doc­tors (or females in gen­er­al, oth­er than the ones we brought along with us).  We can­not look them in the eyes.  We fol­low this pro­to­col because we have been told that doing oth­er­wise would make them feel uncom­fort­able. Instead, our con­ver­sa­tion flows through a respect­ed Afghan inter­me­di­ary. That was the role of the male doc­tor who is their ward director.

But, you see, some­times, and in our sit­u­a­tion in par­tic­u­lar, it is use­ful to talk, such as, when you need to assess their needs for a par­tic­u­lar type of train­ing.  Do they speak Eng­lish?  How well?  Would an Eng­lish speak­ing spe­cial­ist suf­fice?  Should the train­er speak Pash­to?  Is trans­la­tion only nec­es­sary for the fin­er points?

We got off to a bad start. We were hav­ing inter­net qual­i­ty of ser­vice prob­lems. The con­fer­ence qual­i­ty was jit­tery to the point of annoy­ing. We final­ly hacked togeth­er a solu­tion, using the video feed from the poly­com tele­con­fer­enc­ing unit while rout­ing the audio through Skype. At last it was working.

Tele­con­fer­enc­ing is a visu­al medium. When we first fired up the equip­ment and their faces popped up on the screen, I saw the doc­tors play out their instinct to bring their veil to their faces and hide from pub­lic view. We dis­abled the win­dow-inside-the-win­dow on the pro­ject­ed screen that showed us what the doc­tors in Pak­istan were see­ing.   You can hide behind the voice, but not behind a cam­era; but you can think that you are hid­den when the cam­era isn’t reveal­ing what it sees.

When select­ing a loca­tion for the con­fer­ence, we con­sid­ered sev­er­al places with pass­able inter­net.  In the past a con­fer­ence had been sched­uled at the Taj, but the women did not show up because of cul­tur­al issues stem­ming from the fact that it is known as a West­ern­er enclave. So now we were on neu­tral turf at Nan­ga­har Uni­ver­si­ty, (hav­ing trans­port­ed them 10 miles to an inter­net cen­ter that was built by the Rotary Club and to inter­net that was pro­vid­ed by NATO.)

The female doc­tors sat in the front row and the men sat behind them.

Dr. Pete’s main gig is run­ning a com­pa­ny that sets up telemed­i­cine capa­bil­i­ties in var­i­ous hos­pi­tals and field clin­ics around the world.  Though his work­ing rela­tion­ship with Holy Fam­i­ly Hos­pi­tal in Pak­istan, Pete got a female OBGYN doc­tor ultra­sound spe­cial­ist and a female Pash­to trans­la­tor to teach a class on the prop­er use of an ultrasound.

I was play­ing gen­er­al inter­net and audio­vi­su­al tech in the equation.

It start­ed out as a bor­ing lec­ture. The lec­tur­er spoke, the slides advanced. For me the mate­r­i­al was new and there­fore inter­est­ing. I also had the sec­ond occu­pa­tion of observ­ing the entire­ty of what was going on. But the intend­ed audi­ence sat silent and seemed bored.

Were female doc­tors reluc­tant to ask ques­tions? If so, why? Were they shy? Was it old hat and bor­ing? Were we the con­de­scend­ing for­eign­ers that assumed they were mere­ly play­ing doc­tor until they met us and want­ed to teach them a thing or two?

Pete was doing a good job break­ing the ice, ask­ing “dumb ques­tions”, and man­ag­ing the flow.

And then, about an hour into the lec­ture, a new voice piped up. She spoke qui­et­ly and was fur­ther away from the micro­phone so it was hard­er to hear. I climbed around a maze of wires (from the poly­com, the pro­jec­tor, the speak­er sys­tem, the lap­top and attached micro­phone) and brought the micro­phone near­er. The female doc­tors laughed at my park­our moves to maneu­ver the lap­top and not snag any wires. We were begin­ning to win them over.

They asked two or three ques­tions in all. We ran around behind the scenes, print­ing new hand­outs that the Pak­istani doc­tors sent over in response to the questions.

Two hours after it start­ed, the class was over. By way of effec­tive class­es, this was a fail­ure.  Very lit­tle new infor­ma­tion was trans­fered per unit time.

I posi­tioned myself at the back of the class­room next to the male ward direc­tor who has been typ­ing away smart­ly at this lap­top and chat­ting on his cell­phone dur­ing the lec­ture.  He had a long white beard, design­er glass­es, and a tra­di­tion­al white cap. I told him that we under­stand that the class was­n’t per­fect, but that we con­sid­ered this a first test. We would also like to become bet­ter and improve the class­es and to do this we need­ed open crit­i­cism from the doc­tors them­selves. He walked to the front of the room and trans­lat­ed what I said to the doctors.

And then some­thing unex­pect­ed hap­pened.  They turned and start­ed to speak to us direct­ly.  Or, under these cir­cum­stances, I can be for­giv­en for erring on the side of call­ing it direct­ly.  They expressed their needs.  They expressed sat­is­fac­tion at today’s meeting.

At first their remarks were ven­tured in the void, not addressed to any­one in par­tic­u­lar. But then we (also) start­ed to feel com­fort­able to engage the indi­vid­u­als, respond­ing to indi­vid­ual com­ments and weav­ing a com­mon con­ver­sa­tion­al thread. It was a true dia­log.  We took notes: they want­ed large, high res­o­lu­tion actu­al ultra­sound images, case stud­ies, exam­ples of nor­mal and abnor­mal cas­es. (They said that they did­n’t know what nor­mal was sup­posed to be!) They want­ed to be doc­tors play­ing diag­nose-this-patient while star­ing at the same raw image.  They did­n’t need a basic the­o­ret­i­cal review. They had the books and stud­ied them. They want­ed the doc­tors in Pak­istan to show their images, and they want­ed to bring their own trou­bled cas­es to discuss.

(Please “Please for­give the poor audio qual­i­ty and lack of edit­ing, but you can hear the banal­i­ties of the moment for your­self.” for­give the poor audio qual­i­ty and lack of edit­ing, but you can hear the banal­i­ties of the moment for yourself.)

The women ranged in age from the 30s to their 50s and in this con­ver­sa­tion I saw with­in them artic­u­late doc­tors who cared about their patients and want­ed to become bet­ter stew­ards of their health, but also I saw (for­give me Allah for say­ing this) youth­ful excit­ed chat­ter­ing girls.

Pete point­ed out that doc­tors from devel­oped coun­tries have a lot to learn from Afghanistan.   Since it takes so long for peo­ple to get them­selves to a hos­pi­tal, patients present advanced stage patholo­gies. Abnor­mal­i­ties are so com­mon that you almost have to rede­fine nor­mal. He told me that when he spent a day at anoth­er ultra­sound clin­ic in Jalal­abad, he was blown away at the pre­sen­ta­tion of unusu­al in every case. Each would be a case study in Amer­i­ca. You just don’t see that kind of stuff as a doc­tor. More cas­es in one day than he has seen in all his clin­i­cal rotations.

We learned a lot from this ses­sion, sim­ple banal things.

We learned not to ask, but to just give. You end­less­ly wal­low in self-cen­sor­ing cul­tur­al sen­si­tiv­i­ty orbits ask­ing whether you can com­mu­ni­cate with the doc­tors direct­ly, but then again, you can just do it. Don’t ask can we have your emails. Just give a hand out with your own, with the Pak­istani doc­tors emails, the coor­di­na­tors, etc. Add a note describ­ing what role each per­son plays and put the ball in their court.

At the end Qahar, a friend with whom we col­lab­o­rate with on var­i­ous inter­net projects, walked into the room. On their way out, the female doc­tors sur­round­ed him. They told me that he is their com­put­er teacher and their Eng­lish teacher too. It was clear that they appre­ci­at­ed him.

And that appre­ci­a­tion also cau­tious­ly reflect­ed on us. They start­ed to trust us that we actu­al­ly cared and weren’t there to mere­ly wave an illu­so­ry mag­ic wand in the form of high-mind­ed advice and grandiose con­sul­ta­tion based on “The way we do it in America …

***

Of course, it is dis­hon­est to end on such a pos­i­tive note. A cou­ple days lat­er, we went for a sec­ond vic­to­ry. The head doc­tor of the hos­pi­tal where the women worked was sup­posed to have a one on one plan­ning meet­ing with the chief doc­tor from Pak­istan, to plan future train­ing ses­sion for doc­tors from oth­er depart­ments. It was the third attempt to sched­ule such a meeting.

The time was set on both sides, the venue pre­pared, var­i­ous par­ties were involved. And then, he did­n’t show up.

I was sad and it showed when I talked to our friend at the ILC. And he tried to con­sole my by say­ing, “We are used to this. We plan, we talk, and then when it comes time, it does­n’t work out. That’s normal.”

It’s a big chal­lenge to stop being used to fail­ure. It’s a big chal­lenge to rede­fine normal.