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.
