Been a while, 2nd edition

Well it's safe to say I had a regular week! It began in the clinics here in Gabs where I mentored a very capable, and lonely, doc from DRC who staffs a busy clinic in a central neighborhood. One of the interesting things about this area is that compared to a generation ago when there literally was no health care, now any access is generally considered of good quality, which of course is hooey. Suffice it to say that the Gabs MO's run the gamut from caring and compassionate to abrupt and arrogant. Sound familiar? This guy was a member of the former.

The que at the clinic on Monday and Tuesday was literally spilling out the door. Some of the crowding is self inflicted as the MO's want to see all hypertensives back each month. The data shows that we typically need to treat 100 patients for 5 yrs to prevent 3 complications from this disease. So slowly I am convincing them that once every 3-6 months is plenty and will reduce the daily patient load by up to 15%. They are typical of docs with the same level of training in that they over treat from a sense of insecurity and over diagnose just in case they might be missing something. This adds to their fatigue and length of work day. So in there is a compromise that works for all. Added to that is the reliable fact that all patients returning for a blood pressure evaluation ALWAYS have some variety of somatic pain so these visits take a toll on concentration and quality as the path of least resistance is false diagnosis and treatment that once begun is difficult if not impossible to discontinue.

And it gets in the way of emergent care. We had an 8 y/o child with HIV on HAART who had a twoday history of bad impetigo and was septic. He showed up with his grandmother to the clinic. Thankfully he was appropriately triaged and we saw him in a timely fashion. His pressure was down and he was somnolent. We started an IV and gave him a gram of ceftriaxone and then tried to achieve disposition such that he could be admitted without going through the land of no return known as the Princess Marina A&E (emergency room). 

Since he already had a diagnosis and treatment had started all he needed was a peds bed and a doc. I was able to achieve said objective with a few phone calls and had to ride the ambulance (a covered pickup bed) with him to continue treatment. We parked in a different lot much to the consternation of the driver who knew we were breaking protocol, and I carried our boy to the peds ward to be met with a lot of eye rolling and not a little passive aggression. A small nuclear event later said child had a bed and the doc I had called showed up to assume care. MUCH FASTER than going through the A&E, and he is better at this writing.

Two observations. Many children here are raised by grandparents as their parents are living in a different town, dead from HIV, or too young and that's the way they were raised themselves. This of course is not unique to Bots, just interesting in passing. Also, PMH recently underwent an extensive evaluation by a South African firm and was found to be in compliance with the international standards of care (apparently as enunciated by WHO among others) all of 3% of the time(!). THAT is no surprise and just might motivate officials but I'm betting that it won't see the light of day. It will instead be a small change, a bit at a time, dripping with politics.

But I am so very fortunate to be here at this time in my life and career. I love what I get to do, love to teach family medicine and introduce it to the Penn students from my perspective, love to treat. It may not get much better....