Stanford University
Center for Innovation in
Global Health  

On the wards, some thoughts

Posted 5:11 AM, September 12, 2011, by Takudzwa Shumba

Differences in practice

I was sitting with my ward team one morning, and they were discussing how different Dr Gray’s method of practice was from that of the typical medicine attendings. Apparently, he spends more time explaining things to the patients than is habitual. Exceptions to this are ob-gyn and surgery, where more time is spent explaining procedures to patients. I think, though, that a major reason for this is understaffing at the hospitals, and the deluge of patients that denies physicians time to go into greater depth in their explanations to them. I am sure this will slowly but surely change as things get better here.

Nail findings

Zim doctors generally begin the physical exam by looking at the hands (in contrast to the US system where you generally begin from the head). Dr Borok gave the students a bedside clinical skills review session, where she went through the first part of the exam, from general appearance, environment, gait, hands and head. Dr Borok mentioned that an advantage that UZCHS has is that there is a wealth of patients so the students can get a lot of clinical practice, and it is that which makes an excellent physician. Stanford and other US universities are also moving towards greater emphasis on the physical exam and less dependence on technology for diagnosis. Dr Abraham Verghese is Stanford’s physical exam champion (Refer to the Stanford 25 website http://stanford25.wordpress.com/), but I wonder if there ever will be a real emphasis on physical examination in our curriculum or in practice where defensive medicine is a norm.

stethoscope.jpg

Medical devices and innovation

Dr Michele Barry, my Stanford PI, was recently published in NEJM. She co-authored a paper on “Health Technologies and Innovation in the Global Health Arena” http://www.nejm.org/doi/full/10.1056/NEJMp1108040. Going through the wards, I have been impressed by the excellent physical examination skills, and how the training here allows the clinician to weave a differential using more physical findings and fewer tests than would be the case in the US. That said, there are clear cases where technology is needed – for x-rays, EKGs, colonoscopies. In these cases, it becomes clear that overall health goals cannot be met if the technology for diagnosis, prevention and treatment is not available, or if there is not enough capacity on the ground for use and maintenance of these technologies (an area of particular interest for Mambi).
The paper also emphasizes the need for the technologies to be appropriate for the settings they are introduced in, which is where careful needs finding and innovation come in. The paper concludes, “Assessing medical needs, building capacity, and promoting cost-effective innovation will help in realizing technology's potential for achieving better health in low-resource settings.”

Compassion fatigue

Something else my ward team spoke about was “compassion fatigue” – both among practitioners and also relatives of those who were terminally ill. This was in reference to a case where an aunt brought in her nephew in his early teens. He was HIV positive (vertically transmitted), possibly had TB and had very aggressive KS. She had to travel a considerable distance to the hospital, and also had no money for tests or medications. Although she was obviously concerned about her nephew, she made it clear that if there were any costs associated with treatment, she would have to take him home (although it was clear he was severely ill). Another anecdote I heard from Dr Gugu Kabayadondo relates to "compassion fatigue" among health professionals - she was talking to one of the nurses in the wards who had been present during a severe train wreck a couple of years ago. The bodies were put in a vacated room and when relatives came in, the nurses had to go in and identify the individual sought. On one such trip, the nurse found someone who was actually alive and had been left in the room erroneously. She told Gugu that after that experience she needs to maintain a sort of detachment from her patient - she has seen too much to be otherwise and remain sane.

Comments

Sobering note on the challenges of healthcare, my respect for physicians (and aspiring!) grows every day.

Comment by: H at September 12, 2011 5:50 PM

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