In terms of hospital work today, I learned that the things that were on my schedule weren't going to happen. I was scheduled for Neuro rounds (spoke to the consultant = not happening), Gastro rounds (spoke to the consultant = not happening but there was clinic starting at maybe ?10 AM), and Endo clinic (the consultant's phone was off). I ended up hanging out in the resident work room and chatted with a few senior registrars which coincidentally were all women. They were all very pleasant and we discussed the differences in our training systems and call systems. Unlike in the US, there are no such thing as resident work hours nor limits on the number of patients you take care of or admit in a day. You take care of all the patients that need to be taken care of. A couple of them will be in Chicago early next month for a GI conference so we exchanged info. They wanted to know what to wear (is it windy? is it cold?) and where to shop.
I made my way over to the Endo clinic and found that it was in progress. The consultant was there with 2 training physicians. One training physician took the blood pressure and wrote the follow up appointments on their appointment cards. The other training physician filled out prescriptions and lab sheets. The consultant wrote her own notes which later I discovered included the patient's blood pressure, fasting blood sugar (if diabetic), their medications and her signature. Very abbreviated; occasionally some physical exam findings or a sentence or two about the patient if they had any fresh (= new) complaints.
Overall, I was not too impressed by this consultant as she spent very little time interviewing (and examining) each patient. Plus, our patient encounters were frequently disrupted by other patients, ancillary staff, pharma reps (who ended up staying in the room and assisting, more on this later), a visit by a friend with her friend's 7 month old infant (which she held and cooed with) and of course, a bazillion phone calls. Of course, when a patient's phone rang, the consultant would gently scold the patient for leaving their phone on. At some point, I think we were seeing 2 or 3 patients at one time in the same room. I'm getting tired of these lapses in professionalism.
To give this consultant credit, I could tell that she had been quite industrious and traveled quite a bit at endocrinology conferences to present as her original research posters were hung throughout the patient room. She had been to the US for a 3 month posting as well. She was conducting a trial of vitamin E and another medication for diabetic patients with neuropathy. The training physicians were spending most of their time enrolling these patients in the trial (weighing them, taking BP, waist circumference) while she continued seeing other patients in the same room. I'm not sure if there was even really true informed consent.
Clinically, for the most part, the patient were on appropriate medications for their diabetes and they were very good about checking everyone's blood sugar and blood pressure. However, there was an instance in a patient that had uncontrolled blood pressure and wasn't on a type of blood pressure medication (ACE-inhibitor) that has proven benefit for diabetes. I asked about why the patient wasn't started on this medication and basically learned that there wasn't a really good reason why she wasn't. Before asking the consultant, I had quietly asked the training physician sitting next to me and he knew too that the ACE-inhibitor would be ideal but didn't want to ask as well. Plus for the same patient, the patient's family member astutely asked if potentially her diet could be contributing to the high blood pressure. The consultant said no! Ahh... yes... diet contributes to high blood pressure and this was seriously a miss-managed opportunity.
I could tell there was a strong pharma influence in the way this consultant (and subsequently the training physicians) prescribed medications. They were prescribing high cholesterol medications that even in the US are very expensive (i.e. Crestor, Lipitor) that I have no idea how the patients are going to afford them when slightly inferior but still very good high cholesterol medications that are much more affordable do exist (i.e. simvastatin). Later on, this type of behavior made more sense to me as a pharma rep came to visit and stayed in the clinic room for about 1 hour, providing advice about what medications to write for. Talk about pharma influence left and right and breach of patient confidentiality. When I asked the training physician who this person was (the pharma rep), the training physician said he was the pharma rep and that he was very helpful. I guess when you are short staffed, you need everyone to help. But I'm not sure if this type of help really benefited the patients esp when I am confident most patients can't afford the brand name medications that are being prescribed.
I also learned a bit about the struggles of diabetic patients in Nigeria. Insulin is very costly (40,000 to 50,000 Naira a MONTH) and needs to be refrigerated. Clearly by now, you must understand the challenges with simply refrigerating things with shotty electricity let alone just purchasing the medication itself. Thyroid function tests cost about 8000 Naira and take 2 wks to come back. For those patients that enrolled in the study above, they get free hemoglobin A1cs to measure their glycemic control for the last few months. At least they were able to use hemoglobin A1cs to make clinical decisions. Also, the consultant acknowledged that diabetes should get at least yearly eye exams but admitted that the eye clinic was very backlogged. We also did no foot exams to look for foot ulcers which is a standard of care in the US for diabetics.
The consultant did ask me for feedback and I talked about how consultants in the US see the patients every day on the wards. She seemed incredulous about this and quickly said that this wouldn't work in their system. However, I was taken aback by this as the leadership and some consultants in Ibadan had acknowledged the benefits and necessity of increased supervision by the most senior physician. LASUTH has the luxury of having pretty continuous electricity and running water that is not present at Ibadan. But in speaking to this consultant, I felt that despite this facility improvement, the cultural change in medical education and patient care was likely going to be a much greater challenge in LASUTH than UCH.
After taking a breather from the Endo clinic, I ate lunch (I've learned that I just need to step away if I need to eat) and tried to go to GI clinic which unfortunately was already done. Then I tried to figure out if I could go on ward rounds but discovered that had been completed and according to the resident, "I didn't miss anything." Okay. I guess I'll try tomorrow. I'm suppose to go on consultant Cardiology rounds tomorrow. I must at least see this before I leave.
I tried to walk around to take more pictures.
Here is the Endo clinic.
Here is the makeshift "studio" where I got passport pictures taken to have an ID made the day before. I thought it was very appropriate to get an ID (so ppl would know that I was suppose to be around). However, I'm not sure if I'll get the ID before finishing tomorrow.
Here is the front of the modern diagnostic center. Look how one of the doors is opening? Just after I snapped this photo, a guard came out to interrogate me about why I was taking pictures. Of course.
Here is the empty patient waiting area for the medical outpatient clinics.
Being in Nigeria for this last month has been a personally challenging but gratifying experience. I think I am a better person and physician because of it and I know that I will be much more patient and cost-conscious in my medical practice. I appreciate electricity and water on a whole new level. I feel a lot of sadness for the patients I have seen and for the widespread poverty that is present but I have tremendous hope that Nigeria can and will improve in time. Nigerians have been such a good host in making my trip as comfortable and as pleasant as possible. But I still can not wait to go home!
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