What Do You Come Here To Learn?

In my two weeks in the oncology department, I’ve seen a very broad range of malignant disease and things that many medics in the UK will only ever read about in books.

Burkitt’s Lymphoma is something that I first heard about, vaguely, in the infectious disease module of my undergraduate degree. It’s a childhood cancer, linked to reactivation of a latent Epstein-Barr virus and with a genetic component that means it’s seen only in African populations. I’d never seen it or expected to see it in Britain, even with the time I’ve spent hanging around the haematology wards. Here, it’s the single most common cancer diagnosis. A few times when I’ve been on the ward, I’ve assisted with the giving of intrathecal chemotherapy to the paediatric patients, many of whom have Burkitt’s. On my first day, there was one child who didn’t need to be restrained. I hate having to hold children down for procedures, but I hate it more when I don’t have to. If a child lets a doctor put a needle into their spinal cord without making any effort to struggle, there’s something very very wrong.

A second form of cancer that is relatively uncommon in Britain is a retinoblastoma, a tumour that develops on the retina and is almost always seen in children under five years old. It’s considered a rare cancer, with a global incidence of 1 in 15,000, and in the developed world it has a 95% cure rate. In Tanzania, it’s one of the top ten most common cancers and most children present with advanced disease. I have one boy on the ward who has bilateral disease and may never see properly.

We have a list of the top ten cancer diagnoses on the wall of the nurses’ station. The list also includes Kaposi’s sarcoma, choroid carcinoma, hepatocellular carcinoma, and, collectively, the brain cancers. They are all things that are considered comparatively uncommon back home, and the things that we consider common are hardly ever seen here. I’ve only seen one patient with prostate cancer, which is practically ubiquitous amongst the elderly male population in the developed world. On a ward round last week, my intern told me that the underlying cause of cirrhosis is usually liver metastases or a primary hepatocellular carcinoma. I explained that in my city, the underlying cause of cirrhosis is usually alcohol-related liver disease. We don’t have that here, he said.

Of course, there’s always some sort of demographic crossover and some diseases are unfortunately common across the world. I’ve had several patients with breast cancer or ovarian cancer or colorectal cancer. But even then they don’t follow the patterns that a UK-trained medical student would expect them to. I never thought that I’d see a thyroid carcinoma compressing the trachea so badly that we could hear the resultant stridor from the waiting room, or a breast cancer where the first presentation was with lung mets that caused pleural effusion, or ovarian rhabdomyosarcoma in an eleven-year-old girl. Sometimes, they break my heart.

I’ve seen a lot.

A lot that I’m unlikely ever to see again.

And the things that I’ve learned probably aren’t transferable back to the UK — there are different diseases and different drug regimes and in Glasgow they would stop me, horrified, if I ever tried to do an ascitic tap with a grey venflon and a catheter bag. But those things were never the point, anyway. I didn’t come here to learn the SIGN guidelines for malignant disease. I came here, as Tanita said a few days ago, to learn about people. I witness things that we would consider bravery but that are met here with stoicism, and tried to make jokes with the patients who laugh at the mzungu student, and developed a whole new appreciation for how privileged we are at home. I think those things are more valuable than anything I might have happened to pick up about cancer.

“Is it easier to be a doctor in the UK?” one of the registrars asked.

“Yes,” I said. “The patients are still sick and it can be very hard, but I think that we’re very lucky. Because we’re a rich country and we have a lot of available resources, and I think we take that all for granted.”

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4 comments

  1. You may find, you know, that little bits of the experience suddenly become useful at some point. And of course, even the rarest things quite suddenly happen. And of course there is the sharpening up that seeing a wider range of things mysteriously brings. But, yes, in the end, people.

  2. I think that all those things are true, Rosemary. I have learned proper medical things by being here and I have done things that I hadn’t done before — today, I stitched my first real person up — and no learning is ever useless, anyway. But even if I’d done none of those things, yes, the people have been and are continuing to be the most important part of it.

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