Apparently, these lizards are called agamas. The male ones are colored and the female ones are white/gray. The male ones seem to be easier to photograph (it didn't budge as I moved closer) but the female one that hangs out near our water reservoir always scampers away; this was the best photograph I could take of her (can you see it)! Interesting fact: Males are also known to be polygamous with up to 6 female mates at one time. What a player!
Today, I worked in the women's triage hall staffed by family physicians. I primarily worked with a consultant (attending) physician, Dr. Adetunji (the same physician I worked with at the HIV/AIDS clinic) and a Nigerian American medical student from George Washington University. The "sorting hall" is a triage where I understand women, men and children are seen in the order of arrival for any type of complaint. Those that need further outpatient evaluation are asked to purchase a card for $2600 Naira to become an established patient in the family medicine outpatient clinic. Those that need referral to a specialty have a referral letter written on the spot and then are sent to the specialty clinic for care. Those that need some basic work up are offered certain tests that may or may not be completed due to cost.
The cases we saw this morning included rectal prolapse with bleeding, fatigue and weakness in a 16 year old, meralgia paresthetica (essentially thigh pain) in a 58 year old grandmother caring for her 9 month old grandchild and corneal abrasion in a physically handicapped Muslim woman. And of course, we also saw lots of high blood pressure as common things are common worldwide. I was impressed by time and effort Dr. Adetunji took to really connect with the psychosocial aspects of these patients life as we discovered that many of their complaints was layered with social, family and cultural challenges and expectations. He also appealed to my preventive side by taking the time to discuss preventive women's health, particularly with the physically handicapped patient as I learned they are traditionally medically neglected in that manner. Plus, he cleaned his hands periodically with a hand sanitizer!
A few observations:
* There is no such thing as patient confidentiality. The consultant and the senior registrar (= senior resident) each see a patient independently in the same room with a medical assistant sitting in between them to log the diagnosis and referrals and process paperwork for payment. While patients are being seen, other patients and family members wander in and out.
* Patients are incredibly patient and understanding. Many times, their brief visit would be interrupted by the above said visitors and they never voiced any complaints.
* Patients bring in all these different color slips of papers with their test results and even their Xrays and all their medications! Talk about being proactive in your care. I wish my patients would bring in their medications instead of telling me to look in the computer.
* No patient charts are pulled for these visits. If the physician thinks the patient needs further outpatient care, they discuss with the patient if they can afford to become an established patient at which point a card (= chart) will be created. For some patients, sometimes multiple patient charts would be created because the original ones could not be found.
* We didn't really have the time or space to exam patients. The closest examination type things we did was to take blood pressure and use an ophthalmoscope to look in someone's eyes.
* All the patients that carried a diagnosis of high blood pressure and were taking medications for it never offered high blood pressure as a medical problem when asked. It was not until we asked them to show us all their drugs that from their purse, they would produce a variety of medications at which point we deduced that they had high blood pressure.
Later in the day, I participated in a family medicine clinic dedicated to dermatology (skin) visits. This involved about 5 patients in the clinic with a large team of housestaff, residents and senior registrars, 2 visiting medical students (one from Washington DC and the other from London, both Nigerian by birth) and the consultant. Thus far, this was probably the most paternalistic teaching I have seen in Nigeria. We sat in a classroom in rows; the patient sat in front of the room; one housestaff/resident would present from the case study (= chart); the consultant sit in front and direct the teaching and patient encounter. The consultant would interject in the presentation every few sentences, critique (and at times criticize) the training physician, at times, in my opinion, speak as if the patient wasn't in the room and have us standing up and down to look at a rash that was essentially acne or dandruff. If the consultant didn't like the way the resident would be addressing the patient or examining the patient, she would swat the resident's hand away. In general, the consultant seemed to be dissatisfied with everyone's performance. If called on, the resident would stand up to answer and if no answer could be provided, the consultant would quickly call on a more senior resident. She also assigned a bunch of random homework assignments.
To be honest, I was really hoping she wouldn't call on me and I tried to participate as much as I felt comfortable with. The consultant and I probably didn't start out the right note because when we were introduced, I extended my hand to shake her hand. She made a point to tell me I was being impolite by Nigerian standards as the elder is suppose to extend their hand first with me then accepting. I promptly apologized blaming my American habits and ignorance.
From my perspective, it's been quite some time that I've been in this sort of environment. I felt that I was in school again and wanted to slouch in my seat so that I wouldn't get called on. Don't get me wrong, I am all for hierarchy in a manner that is most pleasant for all trainees and safe for the patient. However, this hierarchy seems much higher/prominent in Nigerian medicine than what I've been accustomed to training in the US and becoming an attending in a few short months. Plus, one of the patients we were seeing was a 16 year old young woman with hair loss who admittedly had Asian like eyes and the consultant had to make mentioned how this patient's eyes looked like me which I felt had little applicability to the purpose of the clinic.
I discovered that this teaching style is extremely common in Nigerian medical education as the residents shared with me. On the other hand, the visiting medical students shared my sentiments and perspective having been trained in the US and UK. As a contrast, I described how I would see patients in a specialty clinic as a training physician in which, a similar but smaller team would discuss the case, I would present a plan and we would dialogue about the plan in an warm and welcoming environment that was noticeably less paternalism toward the patient and the trainees. This seemed to pique the interest of some residents. I have to admit that despite any potential drawbacks from this style of teaching, the residents were very engaged and eager to learn and gave much deference to the consultant. This experience helped me gain further insight on the differences in the culture of medicine in Nigeria and the US.
In any case, I will hopefully be going out with a few residents this coming wk or so for dinner to dialogue more about these cross cultural differences at, of course, one the the sanctioned restaurants. I mentioned this to Dayo and learned, for my safety (since I stick out so much), this will need to be preplanned so that Dayo can be around the area in case something happens. I feel so well looked after. Thanks Dayo!
I appreciate all the positive feedback from everyone (yay!) and everyone seems to enjoy the pictures. For those who have never had a generator or a water reservoir out in back of their house, here are a couple pictures. The bigger water tank is the reservoir and the smaller one on the landing is the actual water that is pumped into our house. We pump water from the reservoir into the smaller tank.
Here's a picture of the house from the front including the current security guard on shift. Not sure if he realized that he was going to be in my picture....
Later this wk, Dayo is going to bring me to have Chinese food. Dayo said that I would see "my people" there. :)
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