When Coffee Is More Than Just Coffee
Two years in an Albanian pathology lab
Susan Oupadia | | Longer Read
A pathologist’s work is not easy – and, after two decades, the Peace Corps offered a welcome change of pace. Susan Oupadia learned that, though every country is plagued by the same medical and bureaucratic issues, the cultural challenges vary widely. To help overcome those challenges, enter the Albanian tradition of “coffee” – a lengthy break for collaboration among colleagues.
My work as a pathologist was taking its toll. The daily grind, challenging group dynamics, demanding clinicians, difficult cases that kept me up all night… After 20 years in practice, I needed a break. It’s a feeling many pathologists experience. But, after endless discussion and soul-searching, my cardiologist husband and I decided to break the mold by pursuing our lifelong dream of joining the Peace Corps.
To begin with, we were not at all sure where we would be placed or what we would be doing – but we finally got word that we would serve in the post-communist Baltic country of Albania. The health sector staff at Peace Corps Albania found what was probably the one placement in the whole world that was perfect for me: to establish an anatomic pathology laboratory in the second-largest city in the country.
After three months of pre-service training – living in a village with a host family, attempting to learn the language, sitting through endless required Peace Corps training sessions, and experiencing every possible positive and negative emotion – we were shipped off to our permanent site of Durrës on the Adriatic coast. Little did we know that, when we got there, we would find not only all of the same professional challenges we faced at home, but also a host of brand-new ones.
Starting from scratch
Nothing could have prepared me for my first day in the “lab.” I discovered two almost empty rooms and a non-English-speaking histotechnologist who had spent over a decade doing nothing more than producing distilled water for the hospital. Since the fall of the Communist regime, Albania had experienced a severe decline in public hospital services, along with a general collapse of government and societal structure as a whole. The lab had slowly declined to nothingness. There was no visible tissue processing equipment, only one elderly microtome, and an equally antiquated microscope. There was no pathologist in sight.
A few days later, my husband, who worked in the emergency department, was introduced to a forensic pathologist. My spirits shot up; I honestly believed things were going to be okay. Several sets of slides had been donated to the lab by pathologist friends in the US and I was excited to review them with my new colleague – but, after one afternoon together (with me communicating in my rudimentary Albanian), it became apparent that his fund of knowledge was unfortunately quite poor.
I would show him a slide and ask for his interpretation. Time after time, the diagnoses were completely off-base – an invasive squamous cell carcinoma of the skin was “normal,” a well-differentiated hepatocellular carcinoma was “colon cancer,” and so on. We would check the dictionary each time to make sure there was no miscommunication. I began to wonder just what kind of training existed in Albania. Did all pathologists lack the basics – and, if so, why?
The basic building blocks
Of course, before this service could be realized, I had to find some equipment. Mysteriously, a second histotechnologist showed up one day and opened a dusty closet containing a tissue processor, an embedding station, and a slide stainer – all still in boxes. These instruments had been there for at least two years, purchased from an Italian company one fine day when the hospital administration had seen fit to do so. I was ecstatic to see these devices, because the Peace Corps did not provide funds for projects and I had already been told that there were no hospital funds available for equipment purchase.
My ecstasy was short-lived. We set up all the equipment, only to discover that the processor did not function. Apparently, although funds were allocated for new instrumentation, part of the cash had somehow disappeared and so used equipment had been purchased instead. It took about a month and the assistance of two technicians in the capital city, Tirana, to finally locate the problem: a broken motherboard in the processor’s computer. It took another two months to beg the company in Italy to send me a new one for free. After titling my email “Urgent Request from American Doctor” and explaining the situation, I think the Italian sales representative just felt sorry for me. He knew the many obstacles faced by his neighboring country and probably anticipated the imminent failure of my project – but he helped me, and so I am forever grateful to Giorgio.
A brief history of Albania
By now, I was getting the idea of how things worked (or didn’t) in Albania. I probably need to explain a bit about the culture and the unique character of interpersonal interactions. Don’t get me wrong; the Albanian people are some of the most loving, loyal, and generous I have ever met (and, luckily, they love Americans). However, it seemed as though they didn’t like each other much at all.
After a 500-year occupation by the Ottoman Empire and almost 50 years of Communist rule and extreme isolation from the rest of the world, Albania was a land that knew nothing but domination. Emerging from the Communist regime of Enver Hoxha – which practiced religious persecution, forced labor and military service, near starvation, mass torture, imprisonment, and execution – Albanians developed an understandable mistrust of humanity. During this time, people lived in constant fear of being reported to the police for some real or imagined infraction of the Communist manifesto.
(Interesting fact – over 173,000 concrete bunkers were erected across the tiny country during Hoxha’s Communist rule. These were built to protect against American aircraft bombers, who had no interest whatsoever in the country…)
In the 1990s, as a new “democratic” administration gained political power, rampant corruption, misuse of public funds, and questionable financial and business practices emerged. In 1997, a catastrophic government-led Ponzi scheme was uncovered in which as much as a third of the population lost their life savings. Albanians were in shock.
The resulting mistrust of everyone and everything somehow seemed to have contributed, over the decades, to the people’s deeply rooted custom of “going to coffee.” Literal hours are spent each day in the innumerable coffee lounges across the country. Only through these lengthy interactions with friends, colleagues, family members, and especially new acquaintances or old competitors do Albanians establish a kind of tenuous trust – one that finally allows them to live and work together. It was entirely routine for doctors to invite each other (and me) to “coffee” for sessions of up to two hours during the workday. Multiple coffee sessions with different people were not at all unusual. It is considered an integral part of the workplace and is certainly the one thing that holds society together. And believe me, it is strong coffee.
One may ask then, how does anyone get any work done? The pace of clinical work is unbelievably slow and, frankly, the patients seem like an afterthought. In the doctors’ and nurses’ defense, however, there really wasn’t much diagnostic or treatment capacity in our hospital anyway. The drug cabinets were bare, the X-ray machines were usually broken, and the ambulances rarely had enough gasoline.
The grand opening
After the first year of work, we were ready to host our anatomic pathology lab’s grand opening. (To me, it is still incredible that it took only one year to get the service functioning!) Attended by the Albanian Minister of Health, various other dignitaries of medicine and government, all of the Peace Corps administration, and a host of doctors and medical staff, we had a marvelous photo op and speeches galore. Albanians like nothing more than photo ops. The content of the event doesn’t matter – the importance of the attendees and whether or not one gets a photo with them is the main attraction.
Soon thereafter, specimens began to trickle in. It became apparent that only about one half of the operating room specimens reached our lab. I was not surprised to learn that significant financial gain was to be had when surgeons continued to submit their cases to the private labs in the capital city. It was going to take a lot of coffee to change that behavior. Over time, however, things did improve – and I was particularly happy to hear that it was no longer necessary for patients to carry their formalin-filled containers on the public bus to the outside reference labs (the only way the tissue was going to get there).
Turnaround times in the country were abysmal, with many patients dying of their already advanced disease before a diagnosis was rendered. We tried to win the hearts of the public by achieving and advertising a three-day turnaround time by word of mouth. Many patients brought their specimens to the lab just because they had heard there was an American doctor there. I was just happy that we were beginning to see – and help – more patients.
After many coffees, my relationships with my clinical colleagues slowly improved. However, I still remember the first time I called a gynecologist with questions about a hysterectomy. His immediate and terse response was, “Why are you calling me? I have never had a call from a pathologist in 30 years!” Unbelievably, it turned out that the clinicians generally did not talk to each other. Radiologists did not communicate with surgeons, who did not communicate with oncologists, who did not see the need to talk to pathologists (me, initially). The prevailing attitude was that if you didn’t know the answer to a question, then you shouldn’t be a doctor. The combination of ignorance and arrogance was especially hard to understand and deal with.
I eventually made friends with a hematologist and a surgeon. They kept me sane and tried to negotiate difficult circumstances with (and for) me. I’ll never forget, though, when the surgeon asked me – during an especially long coffee break – if I could change a diagnosis on a thyroid case. It was a benign multinodular goiter that he wanted to diagnose as cancer. “Can’t you just make a little cancer in there?” he asked. “What would it hurt?” You can imagine my horror. He explained, “The patient is very poor and, if she gets this diagnosis, she will get money from the government.”
I’ll never be sure if this was a true story or if there was financial gain or fear of litigation on his end. Fortunately, things ended well; my answer, which included an explanation of medical ethics, cemented our relationship forever. I think he respected me for demanding the truth.
Contrary to most American pathologists’ experiences, patients were often in my office. They came with their wrinkled paper pathology reports, family members, gifts, worries, and feelings of mistrust and frustration with the system. “Unofficial payments” (that is, money given to ensure good care) are a fact of life in the Albanian healthcare system. The expectation is that money will change hands from the patient to the doorman, the receptionist, the technician, the nurse, the surgeon or other clinician, and the billing person, right up to the time of discharge. Only then can one be sure of being attended to at the hospital. Several times, I had to remove currency, hastily shoved in my lab coat pockets by patients or family members, explaining that American doctors did not participate in this system. One wealthy patient, whose thyroid slides I sent to Juan Rosai (who consulted pro bono) in Italy, drew me aside in the coffee lounge and whispered, “If you need anything, anything at all, while you are Albania, here is my phone number.” I felt like I was in a Godfather movie!
A training adventure
Things weren’t always difficult. In fact, for 18 months of my time in Albania, I was fortunate to teach two female residents in their last year of training. I sent out numerous emails to microscope companies in the US asking for donations and hoping for a miracle. Lo and behold, John Hubacz of JH Technologies in California sent us a refurbished multi-head scope! This was a joyous thing. I was ready to start sitting with the residents.
Resident training in Albania takes place in the university hospital in Tirana. In the bleak classroom, there was one dusty old multi-head microscope, disheveled stacks of old reports, no books, and no Internet. Unfortunately, with few shining exceptions, attending pathologists have little interest in spending time with residents. They are told on day one to “go to your room and figure it out” and are basically left to their own devices thereafter. The senior doctors’ dismissive attitude was accompanied by the expectation of “paying respects” and, frankly, well-founded fear on the residents’ part.
Shocking displays of anger and verbal abuse are not uncommon in Albania – not only in the hospital, but at schools, businesses, and other public places. In fact, early on (after being called by the hospital director to train another resident at the Obstetrics and Gynecology Hospital in the capital), I was summarily dismissed by her attending with a barrage of loud, angry words. The resident was sobbing, the lab staff was cowering behind the door, and – luckily for me – my command of the language was not good enough to understand what he was saying. I later learned that the attending believed I had been called there to prove his incompetence and get him fired.
Because of the inequality in payment between public and private hospitals, most attendings work at private labs in addition to the public ones, with attention very much centered on the more lucrative sector – a great disservice to the residents who train in public hospitals. These same pathologists trained in the same system, however, so the only pathologists who seemed to be trained to an acceptable capacity were the ones who had spent time learning their discipline outside Albania. And, of course, these were the ones who had the funds to support this training.
But my two residents, despite the gaping holes in their understanding of pathology, were smart and motivated. Their hunger for knowledge at the grossing table and the microscope drove them to learn as much as they could in the months we spent together. Both rode the public bus for over an hour and a half each way, every day, just to sit with me and learn the basics. My pathologist colleagues elsewhere sent a great library of texts. I also obtained several digital short and long course donations from the United States and Canadian Academy of Pathology, which I presented to pathologists from around the country during a three-day workshop. It was exhausting, but definitely worth the time and effort – to hear the questions and see the glimmers of understanding of things they had probably never heard or understood before. It was a highlight of my Peace Corps service.
The transition home
As our last weeks in Albania approached, I finally saw that my time there – although full of challenges and frustrations – would be something truly unique and unforgettable in my life. I am forever in debt to the Peace Corps, who had the foresight to give me the hardest, but most fulfilling, assignment I could imagine. The small changes I saw in the medical culture – doctors actually talking to each other about cases, asking each other questions, coming to me with questions – never ceased to surprise and amaze me. My husband had similar experiences. Of course, we weren’t going to change this broken society in a major way in just two short years – but the examples we set as American clinicians had made, and continue to make, a difference.
The lab is still operational, despite some temporary closures due to a lack of reagents. One of the residents has become one of my best friends; she’s like a little sister to me. She has immigrated to the US with her family and hopes to take the USMLE and eventually become a pathology resident here. I know she can do it. She has the brainpower – but her confidence sometimes lags behind her abilities, thanks to all those years of dismissal and mistreatment; I encourage her every chance I get.
Returning home was wonderful and difficult at the same time. It has been a rough transition professionally. I love pathology and continue to pursue international opportunities. I read slides digitally from Uganda through the American Society for Clinical Pathology’s Partners in Cancer Diagnosis and Treatment in Africa initiative. I may return to overseas projects from time to time, just to get the feeling of fulfillment I attained in Peace Corps. I have tremendous respect for that organization – they understand international aid and development like many others do not.
The daily grind, challenging group dynamics, demanding clinicians, and difficult cases led me away from my US practice. I found both similar and different challenges in Albania. Even in my late 50s, I discovered I still had much to learn about myself and about humanity and its strengths and weaknesses. I would do it all again in a heartbeat… but only if I can go to more of those coffees.
The opinions expressed herein are those of the author and do not necessarily reflect those of the US Peace Corps.