On Day 19, we started off the day with the internal medicine weekly chart review (= morning report) that pretty much started on time. The house officer read a presentation of the case that was distributed in handouts and offered her initial differential. Then came the registrar (= junior resident) who offered his commentary and differential diagnosis. Then finally came the senior registrar (= senior resident) who did the same. In between these long drawn out presentations, the attendings literally attacked the residents on their presentations like a firing squad. Attacked in an uncomfortable, 'I'm so glad I'm not presenting' kind of way... or at least this was how I and the US trained physicians from my institution that were present perceived it to be.
This case presentation was a poor gentleman that came in shock with a likely gastric malignancy developing tumor lysis syndrome and sepsis. In other words, he had cancer and he was dying when he was admitted. It was so striking that the patient did not receive many standards of care that we offer readily in the US. He needed ICU admission. That wasn't even explored because the patient had no money though this didn't stop the attendings from criticizing the residents about this. He hadn't had labs in days because his family couldn't afford it. He didn't get a chest xray from this admission. In this whole account of the patient's clinical course, the residents described all the resident documentation and interventions. Notably missing was transparency of attending accountability and participation. The attendings were quick to judge and eviscerate the residents; the supervising attending on this case wasn't even around I think. One of the professors from where I work in Chicago (they are visiting) even tried to diffuse the situation and make the discussion more constructive and educational which was quickly dismissed by another attending who said this part of the review was specifically geared so the residents could defend themselves.
In the end, everyone's thoughts on all levels on the possible diagnosis and mechanism of death were pretty consistent and the most redeeming element of this experience was that the patient had an autopsy at death. The findings on autopsy were reviewed and presented. An autopsy at death is a way for physicians to really find out what happened versus what they think happened. In a setting where often times many studies/labs are not completed, I think this component is incredibly important in medical education in Nigeria as it truly provides actual data to understand what had developed in the patient and what ultimately lead to death. In the senior registrar's presentation, he made mention of the studies and labs that should have been completed should the money have been available. I'm just amazed - How can resident physicians and medical students receive well-rounded medical education with these limitations in seeing how a specific condition or complaint is worked up and understood when most of the time, labs and tests and imaging can't be completed?
Following the chart review, the residents wanted to get my impressions. I said it was interesting and very different from how we run our morning reports and how we focus on learning points (and not defending ourselves). The most crazy thing about this whole experience was that all the residents I spoke to thought this experience was very educational. I guess they have come to accept and expect this type of teaching and behavior.
Afterwards, I participated in the Chest unit consultant (= attending) ward rounds. If I thought the senior registrar's rounds was slow the day before, the consultant rounds was even slower with 2 less patients. There was some teaching involved (we discussed the pathophysiology of pulmonary edema (= fluid filled lungs)) but there was even more gossiping and getting off topic that sidetracked us from rounds. I think we even spent about 5 (too many) minutes on rounds dedicated to discussing my religious preferences and why I wasn't a Christian.... in front of the patient. I felt bad.
The consultant spoke very quickly and with a stammer. The residents in private admitted that they often times missed what the consultant said and I often times had to ask him to repeat things when he asked me questions. Generally, I am able to communicate well in English with Nigerians but I find if I'm not paying attention or if they speak real fast, I will miss everything they say. On the flipside, a few Nigerians have said that I speak too fast (just like an American) and that I should slow down. Thus, I've been trying to slow down my speech and spend time on my greetings and asking how people are doing which is very important in Nigerian culture.
In any case, on rounds, we saw the same patients and I must report that not much progress had been made since yesterday. The obtunded patients that need CT scans of their heads and/or sampling of cerebospinal fluid like ASAP (or even weeks before) did not get them. One patient had expired and one patient, despite our efforts to increase his water pill, remained essentially unchanged and volume overloaded if not more volume overloaded. We have a patient with HIV/AIDS that was thought to have a space occupying brain lesion and was obtunded and unresponsive with a new large mass growing on her shoulder. Presentations of disease in Nigeria are so advanced and clinically apparent.
We had a patient that had needed a hematocrit (PCV they call here) for several days and the team wasn't sure if the family could afford it (PCV costs 200 Naira = $1.30 USD). In the end, the patient had the PCV done but if the family couldn't afford it, the residents were going to pay for it. The residents mentioned to me that sometimes when the patient is in a real bind (and really needs the test) and/or the test is quite inexpensive, the residents will pay for the test (i.e. 200 Naira for the PCV) or pool money together to get the medication/supply/imaging for the patient. Talk about blurring the lines between the doctor and patient relationship.
One other thing I learned was that frequently when patient needs tests but can't afford it, the team orders a social worker consult. They order this consult like how I order physical therapy on all my elderly patients. The social worker makes a home visit to the patient's home to find family members to persaude them to get (or find) enough money to pay for health care. Often times, from what I hear, the social workers discover what the residents suspected all along - no money anywhere. There is just a little pool of charity money to go around, maybe just a few hundred Naira per patient here and there.
I think my lack of good sleep (since starting mefloquine) plus eating less than I'm use to eating in a hot and humid environment is starting to take its toll on me. On rounds, I was starting to feel faint to the point they wanted to excuse me but I ate a bit of a Luna bar and drank some water (I carry a bottle around every day), saw 3 more patients (albeit slowly as per above) and was so thankful to eat this lunch.
As it turns out, one of the medicine senior registrar's just passed his part 2 of his fellowship exam and was now a consultant! He provided boxed lunches and beverage for all his colleagues. The residents were very kind to offer me lunch and I just couldn't refuse as I thought I was going to pass out soon. The lunch had two types of rice (one spicy), a piece of chicken, a piece of beef (which I gave away by the time I took this picture) and moin moin (my new favorite Nigerian food). I washed most of this box lunched down with a Coke. One thing in the world that is very consistent I must say is Coke.
After listening to one of the Chicago professor's keynote speech on medical education (which was met with a lot of interest; a medical student who asked a question at the end expressed so much enthusiasm and hope for the opportunities for collaboration that were discussed), Ayo took me to the main non medical campus of the University of Ibadan (UI), the oldest and most prestigious university in Nigeria. Ayo and his wife, who is a lecturer in sociology at UI, live on the campus in subsizided housing for 5000 Naira a month. What a great deal!
They drove me around the UI campus of which the grounds use to be a forest. Thus, lots and lots of trees. Maybe I was imagining things, but I truly thought the air quality was better. The campus is seriously like an gated community with housing, a small market, small health clinic, hostel, exercise facilities, elementary to high school, and even a bank. A self contained little town. What was really nice was the peace and quiet. Granted, there is probably some noise once the generators are turned on, but from what I could tell, there was an absence of honking, yelling and riff raft that is elsewhere. UCH is pretty quiet too but I have to admit that I have some loud neighbors.
We got there too late to see the botanical gardens and zoo (yes, also within the campus) but hopefully before I can visit before I leave. Ayo and his wife Funke were so kind to welcome me into their home. I got to see their simple but homey place. It was so nice to see Ayo and Funke together. They complimented each other so well. It just made me miss my husband.
On the drive back to UCH to drop me off, a young child walked up our car to beg in Yoruba while we were at a stop light. Ayo engaged in a conversation with the child who could be no older than 8 asking him why he was begging and not going to school. Ayo said the young child had no good answer.
Ayo also mentioned to me that the southern part of Nigeria (where Ibadan and Lagos are located) are considered to be significantly more developed and educated than the northern part of Nigeria. He did his year of service in one of those communities and for the whole year, he had NO POWER. For one whole year. He only spoke to his mother once every 3 months. The nearest phone was an hour away. He also shared how its common practice for families in the north to at a certain age, kick out their children to start begging as parents could not longer afford to feed them. I asked about why have so many children if you can't feed them. The answer was that in part it was due to lack of education resulting in lack of understanding of family planning but primarily, this was how they lived. From his perspective, many Nigerians don't believe that health, water, electricity and education are a right in any way. He also said Nigerians pray a lot and have a lot of faith because they can't afford to have anything bad happen to them with so many things going awry already.
We discussed the election results (the incumbent president won). Although this might not have been his desired result, he was happy that the elections had happened peacefully and potentially giving Nigeria legitimacy to the world as an evolving democracy. Yes, I agreed - a step in the right direction. But please tell me, first on the agenda, is to fix electricity problem ASAP, right??
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