Now, on to being a Family Physician

To my right is an open window to help ventilate the 95 degree day, to my left is a glass of water which I am cherishing because the water is off and I am not sure when it will come back on, outside the brilliantly colored--nearly florescent birds--now seem commonplace to me, and straight head of me on the wall is a spider the size of Micah’s hand (the body as my palm and the legs as his fingers).  I am sitting, typing, my spirit is completely content and I am claiming that on this day I am “settled in.”  This day is official for another reason as well; it is the final day of my medical counsel mandated orientation.  I have spent six weeks in the various departments at Queens hospital (the large tertiary hospital in Southern Malawi.)  This orientation has given me many things:  It has given me incredible respect for the physicians who take good care of patients in a very under-resourced setting.  As I compare what I do as a physician with the work of these other doctors, it has instilled in me a deep humility about my scope of practice.  It has given me great appreciation for the time many people have taken to orient me to the systems, protocols, expectations and other details of health care in Malawi. And it has made me appreciate that I am not here to create a new systems but to work within the complex web that has formed over a long time to meet the needs of this culture.  It has given me respect for the stringent process of bringing doctors into this country; though human resources are very limited, there is a commitment to protect patients and the system against poor care or incongruous with this setting. 

Just as I did on during the first week of my orientation, today I walked thought the maze of covered halls and wards at Queens.  I have become accustom to watching the movement of people, hearing the range of sounds from wailing of mourners to the droning of rounds, smelling the dust blowing in and the odor of the wards.  Unlike the first week of my orientation--when I felt completely out of place and in a constant state of astonishment--today I found myself walking down the hall taking it all in and exhaling easily.  Confidence is still a long way off, but the decrease in cortisol rushing through my body is a good change.  On Monday I will officially start working as a Family Doctor in Malawi. 

When I write that sentence an animated mind-map diagram comes into my brain.  Being a family doctor here means many things: it means teaching the principles and core competencies of family medicine to medical students who are hearing the likes of patient centered communication, bio-psychosocial approach, chronic disease management for the first and possibly last time.  It means preparing to be an example, mentor and teacher to the first class of family medicine residents in Malawi, a specialty that is not well understood in this country.  It means working in a district health center as a generalist clinician taking care of conditions I have never seen and trying to communicate though hand gestures or an untrained interpreter. It means trying to carry a vision—ignited by a few Malawian Family doctors--to those who have money and power, that Family medicine is a key part of the solution to many problems in delivering health care in this country.  It means learning about effective health care delivery systems in Africa, how they are funded and what is the path they took.  

Two days ago, I spent the day at Ndirande health center.  It is a place I look forward to spending many more days in the months to come. It is a place that illustrates the problems as well as the potential for success. 

After picking up four medical students her pick-up truck, Dr M came to get me.  The front seat was given to me.  The students, in their white coats, made themselves comfortable in the open bed of the truck and me.  We drove 5km, turned onto a dirt road, and by gently honking made our way past crowds of people milling about and shopping for used clothing and vegetables at stalls fashioned of wood and cardboard.  Ndirande hospital sits in the center of a busy, impoverished, and at at times politically volatile township within Blantyre.  The outside space is crowded with people waiting to be seen.  From an outsiders perspective, there is no clear system and also notably no stress, confusion or concern.  Patients triage themselves—the ones who appear to be most sick are put in the front of the line, otherwise they just wait until they can be seen.   Today only one of three staff clinicians (aka clinical officers) is there; it is not clear to me who comes to work or when.  This CO has worked at Ndirande for some time but his post at Ndirande may be changed  (by the ministry of health) soon for reasons out of his control. He greets us warmly and tells us the he is off to a funeral.  The patients would--seemingly contentedly--wait to be seen until he returned.  

*Vision* A family doctor will be a clinical leader, will bring order, manage the team of providers, and to create a flow that effectively cares for the patients.

The longest lines cued outside are for the “family planning” clinic and the high-risk antenatal clinic so this is where  Dr M and I start seeing patients.  We each take a student and the other two students go off to find patients elsewhere.  There are women who have come for placement of Jadelle (a 5 year progesterone implant which I have never seen before), who have post partum depression, who are uncertain if they have a twin gestation, who have dysfunctional uterine bleeding and are unsure about their age, and one who lost a fetus of about 16 week gestation while bathing and is now having vaginal bleeding. 

*Vision*  A family doctor will provide care to patients of all ages, to handle problems that are both acute and chronic, to know how to stabilize emergencies and identify cases that may become emergencies if not handled in a timely fashion. 

At about 3:30pm our clinical care had to wrap up because a patient required a procedure that could not do at Ndirande (a D&C).  Given the reality that it often takes over two hours for an ambulance to arrive, we figured we were more useful as an ambulance than as clinicians.  With little hesitation, the unstable patient, her guardian (every patient is required to have a care taker when they are admitted to the hospital) and two medical students loaded themselves into the open bed of the truck and we returned to the large central hospital so that she could have her procedure done.

*Vision* A family doctor will solve difficult clinical scenarios in resources poor areas and to work toward solutions that provide the best care with limited resources.

At the end of the day Dr M and I discussed upcoming meetings, proposals to be written and strategies we could employ to improve our ability to take care of patients in a decentralized location such as Ndirande i.e. outside the overcrowded central hospital.  Under the current system the central hospital cannot do its job taking in the sickest patients who need urgent or complex treatment because it is overloaded with non-urgent concerns. And the district hospitals can not do their job because of a cycle that resolves around, lack of resources leading to lack of effective care delivery leading to lack of provider satisfaction and patient trust leading to perceived lack of value which cycles back around to lack of recourses allocated by the government.   

*Vision* A family doctor will be an advocate for reforming the system so that patients can receive the care the need when they need it. 

And the final conversation that we had was exchanging thoughts and hopes about one of Ndirande’s clinical officers (L) who has shared our passion for Ndirande to become a fully functional district hospital and pilot for other district hospitals in Malawi.  L was recently offered a “project job”.  This is a common path for the best and brightest clinicians in Malawi.  As is the case with L a private research project, who needs a clinician for a short time, will offer her a salary that exceeds a government salary by three times or more.  Having just started a family 8 months ago, the obvious choice for this talented, passionate young clinician would be to work for the private research project.  But, by some miracle, she has not yet made up her mind and is considering staying at Ndirande to work with us to promote this vision.  Last week one of my dearest friends in Seattle gave a donation to Ndirande.  This donation bought a couple of beds, a desk, a lock box for controlled medications (so that patients can receive anesthesia), a lock of for the door, and set of bars on the window (as things had been stolen quite often), some curtains for patient privacy, and some other necessary clinical supplies.  To this clinical officer, this donation was a timely and compelling symbol that there is potential for this hospital.  The things we were able to purchase represented a transition taking place: an intangible vision-- that Ndirande could be a model district hospital--becoming tangible.   And this gift provided hope enough for this talented clinician to consider saying no to money and yes to a dream. 

It is my hope that this gift may have put a small break in the cycle described above that nothing leads to nothing at Ndirande.  We now have something and I pray that there is more to come in small and large ways.  Thank you T for your generosity, it has value beyond the monetary value!

*Vision* A family doctor will strengthen teams, share vision and help create a sustainable work place for talented clinicians. 

This day, next to the giant spider, I feel both settled and also hopeful that we will be able to unsettle the status quo at Ndirande.