We can do it... and we need more of us.

March 1^st 2015

My role here has developed many tentacles.  It seems that opportunities to teach or assist with clinical care pop up around me often.    Many of these opportunities pass me by because of lack of time or expertise, but more often than I expected I have a sense that I would be relatively well equipped to help.  Though I have to be careful that I don’t jump in to too many things, having the realization that a person like me could fill this role gives me a little boost of family medicine pride.  It feels like the fact that I could do it is evidence for my side of the unspoken debate: On one side of the debate is the argument that Family Medicine is not needed in this country, it is functioning well enough with the specialties it has.  And more energy should be put into higher-level specialty care rather than broadly trained primary care providers.  On the other side of the debate is the argument that Malawi is building a healthcare system without a solid foundation.  There are silos of health care delivery that are not integrated, and vertical programs that forget the whole person and the context within which that person is experiencing illness.  A family physician at the foundation of the health care system is imperative to provide comprehensive care where for a wide range of interwoven conditions close to where patients live.  

So when a family physician is well suited to respond to these teaching or clinical needs, it makes me feel like I can showcase family medicine in a practical way.  Thus, this is proof that more family doctors are needed in this country.

Last week the department of Family Medicine was asked to teach a geriatric conference to clinicians and nurses that are working to set up a brand new “geriatric center for excellence” just outside of the city.  This clinic and hospital is situated in a rural area. A grant supported the building of this hospital out of the recognition that geriatric care is lacking in Malawi. This will be the first hospital dedicated to geriatric care in the country. Martha and I visited this site a few months ago. It has an impressive structure in place with a new ward being built, a beautiful chart filing system, modern furniture and a fully stoked pharmacy. It appears to be a very impressive start.  The program manager gave us a tour of this facility and told us of the plans to make a “geriatric center of excellence” with a lab, operating room and ICU.  When it was time for questions I wanted to know about community outreach, multidisciplinary care, social services and palliative care.  The response was mostly in facial expressions which I understood to be mostly brushing me aside with a hint of curiosity.

At the end of the tour Martha and I were asked to help them with strategic planning and also with teaching.  The clinicians and nurses hired to staff this hospital felt unprepared to take care of the elderly;  geriatric care this is not a core part of medical and nursing training in this country.  For us (on the college of medicine side), the longer-term vision is that this hospital could serve as the geriatric training site for the Malawian Family Medicine Residents in their third year.  To begin this symbiotic partnership, we decided that we would start with a 3-day course on geriatric care followed by once a month clinical teaching at their site.   

Personally, I am fine with geriatrics. I had amazing teachers in residency who continue to teach me as an attending (thank you Carroll Haymon, Carla Ainsworth and Sarah Babineau!)  Geriatrics continues to be one of the strengths of our program at Swedish.  The faculty are strong, the experiences that residents get are rich and geriatric patients receive excellent care from our residency. I am thankful to be amidst that at Swedish. But I would not say that Geriatrics is a passion of mine.  I am glad that I get to think about geriatric care in the midst of everything else.

But teaching this course was one of the most deeply satisfying teaching that I have done in a long time.  The course included the topics that you would expect: dementia, medication management in the elderly, vision and hearing loss, incontinence, palliative care etc.   These medical conditions were largely new and our students were interested, engaged and taking notes. But what was most satisfying was to introduce what I understand to be basic concepts for the first time: goals of care, minimizing harm, considering the risks of polypharmacy (prescribing more than 5 drugs at the same time), and family meetings.  These clinicians are taking care of the elderly and this was—for some of them—the first time that they had thought that providing medical care is more than choosing the right drug or doing the right procedure. Seeing the mental gears moving as they consider for perhaps the first time how comfort care can be a priority over curative care was a profound experience.  I understand why these providers have not learned these concepts before.   A very low resourced setting like Malawi needs to focus on the health problems that matter most.  Curative care is what clinicians are nurses are taught because it matters… children under 5 years die of curable causes everyday, pregnant women die during uncomplicated deliveries, people of all ages die from infectious diseases for which there is good treatment. So this is appropriately where the emphasis is.  But when you are talking about a 90 yo patient with end stage dementia and urinary incontinence, the most important issue is not what medication to use.  We also discussed that having a fancy operating room is not as important than having an effective community orientated primary care system where health workers can interact with the community and bring vulnerable elderly into the clinic or the hospital when they are ill.  More than a laboratory with expensive lab tests, it is important to educate families and caregivers about the conditions of their loved ones so they can act as extensions of the health care system. 

It feels good that in 2 ½ years our Malawian Family Medicine residents will rotate in a geriatric hospital that is truly is a “geriatric center of excellence.”  It feels good that I had some role to play in challenging these clinicians to consider how treating geriatric patients is unique.  And it feels good that some elderly patients will receive some holistic care as a result of this conference.  Family doctors can teach and practice these principles.  We need more of them in this country!  I was a philosophy major in college so I am allowed to have my own private debates AND win them.