Today, 2 professors from the medical school where I train arrived for their weeklong visit to share innovations in medical education. From speaking to them and the fourth year med student from Chicago (who is originally from Ghana) that just arrived for a 2 wk elective in radiation oncology, I now get the sense that I am the more experienced and wise visitor in Nigeria. As I described the power outages and adaptations I have learned to adjust to the variety of things that can happen in a day, I could sense their confusion and apprehension. Don’t worry – the amenities in UCH are quite posh in comparison to elsewhere (i.e. the bush) and we have had pretty consistent light for a while.
What I’ve learned about internal medicine and family medicine at UCH is that family medicine is a strictly outpatient practice and solely provide the primary care to UCH patients. Family medicine residents do rotate in pediatrics, internal medicine and OBGYN wards and when any of their patients require admission into the hospital, they get admitted to one of the above services. Thus, the type of power struggles and not wanting to step on each other feet that I’ve experienced in the US does definitely happen between family medicine and internal medicine.
Internal medicine wards are divided by specialty – Chest (= Pulmonary), GI/Liver, Neurology, Dermatology, Endocrinology and Cardiology and they each have outpatient clinics once to twice a week. However, internal medicine doesn’t provide any primary care at UCH unlike where I work where general internal medicine (including the residents) provides the primary care as we have no significant family medicine practice. Another difference I noted right away was that there are only a handful of women in the internal medicine residency program as opposed to almost half of the family medicine program who we women. As women marry and have children (an ingrained cultural expectation), family medicine, given its outpatient nature, is felt to lend to a lifestyle where one can bear and raise children. One of the woman internal medicine residents had described internal medicine as more stressful with longer hours. Surgery is worse with only 1 woman in the program at UCH.
Today, I attended senior registrar (= senior resident) ward rounds in the Chest unit with his team of house officers (= interns) and registrars (= junior residents). I was struck to learn that the consultant (= attending) only rounds with the team twice a week. Yes, only twice a week. The senior registrar rounds with the team at least once a week. The registrars see the patients they are following at least 3 times a week and the house officer sees the patient daily and writes notes or transcribes them form the consultant or senior registrar. It seems like within levels of the hierarchy, there is some degree of communication on a daily basis esp if a patient is going to be sent home. However, even the residents acknowledge lapses in communication and supervision. Sometimes, I hear the consultant even refuses or is MIA for the twice a week rounds. Seriously?
During rounds, we saw a service of 14 patients, many of who had complications from tuberculosis – someone with right heart failure from chronic lung disease due to tuberculosis who was volume overloaded (= body backed up with water), a young woman with a dropped lung (= pneumothorax) and a couple of men with a lung filled with pus (= empyema). A common theme was that due to financial constraints of the patients, most had only a chest xray but none had a CT scan of the chest to better look at the lungs. Sadly, I learned that a CT scan costs 40,000 Naira which only is a little over $250 USD but the minimum wage in Nigeria (that isn’t widely adhered to) is only 18,000 Naira a month. Thus, poverty, sickness and even death all are very much intertwined and determine health outcomes in Nigeria.
In a hospital in the US, when doctors order tests or labs or medications for patients, a process is initiated to get that test completed, lab drawn and medication shipped up to the floor and administered to the patient. Here, if physicians would like to order any test/lab/medication, they write a prescription or on a random little slip of paper a specific order and the patient’s family needs to pay for the test or lab or go to a pharmacy nearby to pick up the medication and bring it back to the nurse to be administered. (Can you even imagine patients in the US doing this?) Thus, the senior registrar was telling me how there were lots of problems of fake medications as many families seek to purchase medications outside of the UCH due to cost. In some cases, family place a deposit down for the patient and the medication can be directly ordered from the UCH pharmacy and the cost is deducted from deposit. In this situation, the quality and authencity of the medication can be confirmed. This made me wonder if one of the patients that had purchased a water pill to remove fluid was even really getting the water pill.
We also saw a few HIV patients that we referred to as retroviral patients with pulmonary issues and a few stroke patients that due to service politics (similar to where I work) led the patient to stay on the Chest service and not be transferred to say the Neurology service which would likely be more appropriate (they didn’t transfer because they couldn’t get head CT due to financial constraints). One stroke patient we discussed quite a bit was a 50 some year old man that had a catastrophic stroke 7 days before. He had not regained consciousness, was unresponsive and showing signs that he was becoming infected (= septic). His family was poor and had no money and since his transfer to UCH, nothing with exception to supportive care (IV fluids, oxygen) plus a little antibiotic (ceftriaxone I believe, family couldn’t afford Flagyl as well). I was curious to see how much the family understood had happen and whether the medical team had discussed his overall guarded prognosis. I guess what I learned was not surprising as the medical team had not had these conversations in part due to cultural and religious factors.
In Nigeria, the literacy and education level is very low, particularly among young women. This translates to low health literacy and poor understanding to family planning (which is another topic for another time). As such, the residents feel that despite their best efforts to discuss what was going on would be met with much confusion and lack of understanding. It’s not uncommon for family members that round up enough money for a CT scan to think that the CT scan is a treatment and not just a purely diagnostic tool to guide treatment. Furthermore, as I have eluded to in prior posts, Nigerians are overwhelmingly religious. Whenever I discuss reliability of power, reduction of corruption, improvement of education, clean water for all, Nigerians almost all say that they pray for these things to happen as in light of their daily hardships, their faith is what carries them through each day. I’ve come to think of Nigerians are very resilient and faithful individuals. Given this religious context, to even broach the topic of palliative care or hospice or even to give warning for a very poor outcome may be interpreted as the physicians giving up and being “a devil”. It was painful to learn about the clinical course of the 50 some year old man that had a catastrophic stroke and was actively dying (in my opinion) in part given that no substantial medical intervention had been occurring due to poverty. The next day, I had learned that he had passed away over night. Poverty sucks.
Another notable thing was that patients need to purchase gloves to provide to the physicians to exam them. (If I had known this before I came, I would have brought with me boxes and boxes of gloves with me.) For whatever reason, possibly due to the lack of running water to wash hands, the residents have grown accustomed to examining patients with gloves and due to (again) financial constraints, often only the senior registrar was the only one examining the patient while the others stood around and observed. Not necessarily ideal for hands on learning. One thing the senior registrar did an excellent job was patient modesty in terms of drawing the curtains surrounding the patient’s bed to give them privacy during the physician exam.
Our rounds were sort of slow as we often got derailed by random gossiping and topics. I was contributing to this for a while but then I started to feel bad as we were having these conversations in front of the patients in the middle of our evaluation of them. Later, as I observed, this was a standard that was deemed acceptable from the top down from the attendings. I did quietly say something to the senior registrar and what I think resonated most with him was that despite any poor role modeling that may be occurring, we as residents know what the standard should be (all the residents agreed that we probably shouldn’t be gossiping in front of patients) and we should strive to meet these standards. I get a sense at the residents feel overworked, under appreciated, abused (I later saw this the next day), underfed (internal medicine residents barely eat as well) and working with too much independence and too little supervision for their level of training.
We also talked about obesity as of course the common thought is that American patients are quite obese. I couldn’t refute that. In Nigeria, I had seen far fewer obese patients. In fact, obesity in Nigeria is something people are often proud of as it means that they are well off and have enough to eat. However, on the flip side, the residents acknowledge that they had been starting to see more diabetes and heart attacks that are definitely contributed by obesity.
Later in the day, one of the professors from Chicago where I worked gave a pretty interesting talk on clinical reasoning and how we might teach trainees how to think like doctors as the process of how we come to diagnosis something is often not organize and fraught with error. Before this talk, I again spoke more Chinese! I too was got off guard by this. A visiting medical student that was Nigerian by birth, educated in Ghana and was attending medical school in Najing, China due to unknown reasons by me knew a bit a Mandarin after living in China for the last 5 years. Speaking a bit a Chinese with him was kind of cool at first until I started to get the sense that he wanted to know me better so that I could him to get to the US. Of course, we again had that conversation about how I wasn’t really American because I must be some Asian.
In other things, I’ve finally succeed in taking a picture of a hospital ward! Hospital wards are separated by gender and are mixed in terms of what service they are admitted under. Wards vary in size with as little as 14 patients in a room up to over 30 patients in one room.
Here is a men’s ward with over 30 patients. They are separated by curtains and each bed has a bed net for the evening. See the different teams rounding.
Will catch up tomorrow. Goodnight!
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