Day 20: Chest Clinic, Free Food & Lagos

Little did I know that Day 20 would be my last full day working at UCH (more on this later). I started off by going to a resident lead dermatology lecture about bullous lesions (I wasn't very interested) and got called away to participate in Chest clinic with the same consultant that had lead ward rounds the day before.

I hadn't had the best impression of this consultant given our protracted conversation about my religious beliefs on rounds in front of the patient the day before but I have to admit I enjoyed seeing clinic patients with him. Of course, while in clinic, there were several gossiping interludes. However, we did some good work and he was very receptive and curious about my observations and feedback. He even admitted that increased resident supervision would be beneficial and that sometimes he will round on his own on the non consultant rounding days to make sure nothing was being missed.

We saw a 70 year old patient presenting with signs of right heart failure likely due to longstanding emphysema. Here is this man's chest xray. He was a smoker, had TB in the past (MDs - can you tell by the CXR?) and had engorged veins in his neck and swelling of his legs. We talked about optimal therapy and it no longer surprised me that first line medications we use are not necessarily prescribed up front (due to cost), spirometry to evaluate lung function wasn't available in the clinic (in fact the full PFT lab had been closed for a couple of months because the equipment was broken) and that in order for the patient to receive oxygen (which has been proven to extend the life of those with emphysema) he would have to be admitted. There was no such thing as home oxygen.


We also saw a middle aged woman with presented with recurrent hemopytsis (= coughing up blood). She had an episode many years back and now recently had it. It had since resolved.

This was her chest xray 5 years prior.



Here is her chest xray currently.


What we see here are cavitary lesions in both lungs. However, in time, she had developed a fungus ball in her right lung whereas before she only had it in her left lung! Aspergilloma! She had prior history of treated tuberculosis and this type of fungus loves the cavities that TB creates in the lung. I had seen this type of lesion before on CT scan but not so clear and prounounced on a chest xray. This patient we referred to a cardiothoracic surgery to see if she would be a candidate to have the fungus balls resected. We all knew that a major limiting factor would be (as you know by now) - money.

We had another patient that had complete opacification of the right lung, suspicious for fluid and/or mass. We attempted to sample some pleural fluid from the lung (= thoracentesis) with the current supplies that were available. Alcohol to clean the area from a metal bowl. Cotton balls to apply the alcohol. The clinic had a few needles and syringes that were free of cost to the patient. This patient had a bit of adipose (fat) in her back and we needed a longer needle to access the pleural space to get some fluid. We had to write a prescription for this needle; the patient's family member when to go purchase it and then we tried again. This delayed the procedure by about 1 hour. Unfortunately for the patient, the physician had no free lidocaine and he had said that families often balk at buying lidocaine to numb up the area where the needle was going in because of cost. Thus, we had attempted this thoracentesis without lidocaine and I could see that she was in a good deal of discomfort. The consultant said he might go buy some lidocaine himself and use it on patients in the future. This procedure wasn't successful (we didn't get any fluid) and the consultant was suspicious for a mass. We ordered a CT chest for her; hopefully, her family can afford it.

Later in the day, we had an abbreviated ward rounds for one of the visiting professors from where I work in Chicago. The residents presented three of our patients and I very much sensed a high level of deference the residents and consultant had for the visiting professor. This visiting professor is known for his teaching, physical exam and clinical diagnosis and he didn't disappoint. I think it was nice for the residents to see a consultant teach at the bedside in a nurturing, non-adverserial approach. The last patient we saw was basically comatose with a severe neurological lesion - very brisk reflexes and upgoing Babinskis on exam. She had no lumbar puncture and CT head and looked as it death was not far away. The visiting professor and I discussed this case in private later and we were both amazed that this patient had deteriorate to such a clinical condition with such clinical findings. We both knew what was going on and why it was going on.

Following another lecture by the visiting professor on clinical reasoning, there was an outdoor reception for the visiting professors and UCH medical students, residents and consultants. There was free food and drinks so you can be sure the hungry trainees were all around! There were fried donuts, finger sandwiches, pieces of chicken ( a little bit random) and pieces on beef on a toothpick (also a bit random). I was hungry and had some food - no diarrhea illness I'm happy to report!

There was a photographer going around to take pictures. I had noticed a few photographers at a variety of events I had been to over the last few days, esp with the professors from Chicago visiting. I assumed they were part of the university. However, I later learned that they are freelance photographers that take your picture and then ask you for 100 to 200 Naira. Shady, eh?

Here are some pictures from the reception with Dr. Oluwatosi, a surgeon and a friend of Dr. Sola. Dr. Oluwatosi has called on me periodically to make sure I've been doing well.


Here are a couple of the women medicine residents. There are a total of 8 women in a program of 30+.


Most of the residents and medical students that spoke to the visiting professors asked the number 1 question - how can I rotate/work in the US? One medical student even brought out one of our major medical textbooks to have one of the visiting professors autograph it (she wrote a chapter in it). In addition to having someone from "home" to chat with, the arrival of the two visiting professors from Chicago raised the oyibo contingency at UCH by 200%!

Later at night, I received a call from Dr. Sola. The Lagos hospital strike had resolved. Since I was planning on going to play in Lagos for the long weekend (Friday is Good Friday, Monday for Easter and Tuesday is election day), we decided on the fly that it might be a good opportunity for me to rotate next week at the Lagos teaching hospital, provided we could arrange for the clinical experience and accommodations. Plus, Dr. Sola wanted me to see a Nigerian hospital where things were running smoother without as many of the struggles of UCH and tests were available and ordered for patients (not sure how this happens with all the cost issues) so that I could leave with a more complete picture of health care in Nigeria. Thus, tomorrow, Day 21, would be my last day at UCH and we would be off for Lagos on Friday.

Stay tuned!

Day 19: Morning Report, Rounds & University of Ibadan

I'm very behind on blogging now given all the issues with either internet (I was starting to think our provider turned off internet at 8:30 PM every night) and of course power. We're on the gent now and I'm trying to enjoy it before going to bed for the night.

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??

Day 18: Internal Medicine, Poverty & Religion

Day 18 was the day I started my internal medicine posting (= rotation) and less than 2 wks before I return to Chicago! I’m in a nice rhythm of things at UCH – I sort of know my way around and recognize people while I’m in the hospital. I know where to get phone credits and I’m just about finally acclimated to the daily interruptions in power. I’m use to eating my carb heavy diet with a daily egg or two for protein and despite lots of carbs, I think I’ve lost some weight probably from all the sweating I’ve been doing. I’ve told Eddy that I want fresh fruit and Piece pizza and salad upon arrival home, in the airport if at all possible.

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!