Thursday, April 26, 2012

Clinical Reflection from Gabs

Here is another journal about some experiences and reflections of the clinic in Gabs. It picks from several points throughout the semester. Enjoy!

Since my last journal about my experiences in the Broadhurst 3 clinic, in Gaborone, I have learned many things. On February 31st, I shadowed the ARV doctor. This was my first experience of shadowing a doctor in Botswana. Since one of my main areas of interests in the humanities is the ethical issues surrounding patient autonomy and the doctor-patient relationship, I was excited to begin learning about this in Botswana. The doctor I shadowed on this day was a quiet man from Ethiopia, who gladly welcomed me into the consultation room. Most of the patients he saw on this day were people who were returning to refill their ARV medication. The basic procedure when this is done is as follows: the patient will come in 2 or 3 days prior to consultation, to have his or her blood drawn, then the patient comes in to see the ARV doctor and review the current status of the disease. The basic points of concern from the blood test are CD4 count and the viral load. Mature helper-T cells express the CD4 membrane protein and are referred to as CD4+ helper-T cells. The CD4 count measures the concentration of mature helper-T cells present in the blood. The viral load measures the amount of detectable HIV virus in the blood. Patients enter the consultation room and hand the doctor their identification card and patient file, and the doctor begins analyzing the blood test. If the patient is just beginning ARV treatment the doctor will ask if they have any questions about the treatment. At this point, the patient will have already undergone counseling, and the doctor is simply following up to make sure everything is clear. If the patient is returning for continued treatment, the doctor will explain the results and discuss the status of the current disease.
            My first impression of this entire process was that it is very technically sound, but personally detached. The doctor that I was shadowing on this day did not seem to take any particular interest in the patient. Rather, he was immersed in the test results, and very much focused on the numbers on the paper he was interpreting. While this in itself is not a bad thing, in my opinion the separation from the patient is a problem in the field of medicine. It is true that every doctor (or provider) is an individual and will have a unique way of addressing patients and handling daily duties. Still, the problem at hand is a real one, at least for those who still hold the art of medicine—as compared to the science—as valuable. The struggle to find the correct balance between the art and science of medicine is one that is far from new and far from being resolved. In the real world of practice, it can be extremely difficult for patients to get the time and attention they deserve. A Cuban doctor we spoke to in Serowe echoed this problem, describing a Cuban system that was almost facing the same trouble at the other extreme. In Cuba doctors are penalized for ordering too many negative tests. This forces doctors to be much more hands-on, obtaining from the physical examination the most possible information. It has been my conviction that the straying from the physical examination as the primary tool of a doctor is one of the greatest problems in medicine. My experience in Botswana has confirmed this as a threat not only to American medicine, but also to medicine worldwide.
            My next experience in the clinic was with the general doctor. Here patients presented with all sorts of different ailments, including: sexually transmitted infection, tonsillitis, chronic hypertension, asthma, and skin irritations. This is a pretty standard list, with not much difference of what one might see in the U.S. I have found it interesting that hypertension and diabetes are major health issues, in this country, since obesity does not seem to be one. Interestingly, I was told that the diets here are very high in starch and energy. I have noticed this as well in my own experiences. The main dish at nearly every meal is overly large portions maize or sorghum based porridge, which are exceedingly high in energy. On campus, the snack item of choice is a fat cake. This is basically deep fat fried homemade bread, and is made in mass quantities at every cafeteria.
            In addressing these problems, the doctor told me that he is required to process each patient through quickly. He even mentioned that he has been warned by the Ministry of Health for spending too much time on individual patients. As a result, he was very quick in his work, and very quick to prescribe medication. This is another major problem that I have noticed in every clinic I have been to. Prescription of antibiotics and painkillers is given with alarming ease. If a patient presents with an infection of any sort, antibiotics are prescribed immediately. As is well known, the effectiveness of antibiotics is diminishing quickly, in large part due to over prescription by providers. The doctors here do not seem to recognize this, and do not even counsel patients on the vital importance of adherence to these drugs. This doctor was also very quick to refer patients when they seemed outside his ability to treat. For example, one patient came in with an eye irritation, and without even being examined; the patient was referred to another doctor, since the eye seemed to be an area off-limits to this doctor. A similar situation arose many times, and I was surprised that the doctor was so quick to move the patient along, without even performing an examination. As mentioned, this is part of the requirement of his job and is, unfortunately, an expected outcome of dealing with a heavy patient load and minimal personnel.
            Since returning from our visit to the village of Serowe, I have visited the clinic twice. The first time, I returned to the ARV doctor, to continue learning about treatment of HIV/AIDS. The doctor on this day was from Zambia, and had a much different personality from the first that I shadowed. Before, I assumed the language barrier prevented the doctor from meeting the patient on a level suitable for intimate discussion. The Zambian doctor I shadowed this time around, however, was very sociable and managed to get the patients to open up much more than before. He was able to understand when a patient was holding back, and find the right words to make them open up to him. This gave me confidence that while patients prefer to speak Setswana when discussing such important things, many are still able to communicate effectively in English when the doctor is able to take control of the conversation. This is especially true in the city, Gaborone.
            I also gained many more insights into how ARV treatments are delivered. One young woman came in who was fighting tuberculosis. When an HIV-positive patient is also infected by TB, ARV treatment is started regardless of the CD4 count. This means that the patient will have to remain on ARV treatments for the rest of his or her life. This is especially unfortunate in a young person, since treatment is not to be stopped once it has been started. Since there are only two lines of treatment available, this increases the patient’s chances of becoming resistant to both lines sooner. One of the main challenges of ARV treatment is to make sure the first line of drugs lasts as long as possible. Once the patient begins to resist these, treatment becomes exceedingly difficult.
            In many cases the antibiotic cotrimoxazol (CTX) is given as a prophylaxis against opportunistic infection along side the ARV treatment. However, this antibiotic has many severe side affects and cannot be given to every patient. When it is not given, the patient is at an increased risk of acquiring an opportunistic infection. Prescription depends on the health of the liver, as determined in the blood tests; as well as by the overall health of the patient. The ARV doctor must account for both of these in discerning whether or not this antibiotic ought to be prescribed.
            I also learned that the Ministry of Health would soon be increasing the CD4 count required to receive ARV treatment. At the moment, the count is <200cells/uL, the change will increase it to <350cell/uL. The positive side of this is that patients will be able to start treatment before the HIV virus has begun to attack the immune system so seriously that it is hard to recover. However, from the perspective of the medical system, the patient load will be dramatically increased, while the personnel numbers will struggle to keep up. In addition, patients will begin treatment at a younger age, increasing the likelihood of becoming resistant to the ARV medication.
            Interestingly, I asked this doctor to compare the medical system in Botswana to his experience of the one in Zambia. He told me that when it comes to treatment of HIV, Botswana is much more advanced. For example, in Zambia the viral load is not even considered in ARV treatment determining how to organize the ARV regimen. While praising the free system, he also warned that a host of problems also follow with the system of free care in Botswana. Many of these have been described in this short reflection.
            My final conversation with the ARV doctor was about the reasons for the success in lowering the rate of new infections in Botswana. In addressing the culture, he gave two things that have allowed the campaign to be successful. First was the decrease in the taboo on talking about sex. He told me that patients today are open to talking about issues revolving around sex. They now understand the importance of these conversations, especially in the health field, and are willing to do what is necessary for their health.  Along these lines, patients are also much better informed now. Since patients are better informed about the nature of HIV and ARV treatment, they are better at taking necessary steps in their lives to treat or avoid HIV. While this is not universal, the sentiment is beginning to spread strongly throughout the country, and is allowing for the fight against HIV/AIDS in the country to take a turn for the best.
            My final experience, thus far was with both the HIV-testing clinic and then again with the general doctor. I arrived at the HIV-testing trailer in the morning, but the line was not very long. I assisted in the testing of several patients before the line dwindled. Even with all of our immersion in the problem of HIV in Botswana, it is still startling to see someone find out for the first time that he or she is positive. On this morning, I witnessed this happen to a man from Zimbabwe. The man claims to be faithful to his wife, but does not use a condom when sleeping with her. Unfortunately, since he is not a citizen of Botswana, he is unable to receive free ARV treatment. The counselors rattled off the practiced speech about finding a trustworthy person to discuss his situation with, as well as the importance of urging the wife to be tested. While this man was clearly surprised by the results, he was not very inquisitive; and beyond simple questions, the counselors did not make a rigorous effort to really understand and inform this patient, who had just been given life-altering news.  
            Once the testing clinic became stagnant, I moved to the general doctor. This doctor was from Ethiopia, and had been trying to find a job in the U.S. for some time. He has taken all of the required licensing tests, and has been attempting, unsuccessfully, to obtain a hospital residency position. His reason for desiring this was the opportunities that are opened up from having residency training in the U.S. “You can practice anywhere in the world,” he told me.
 Since my time with him was short, we did not see many cases. One interesting case was a woman who showed signs of an STI. The doctor told me that it could be caused by any of multiple organisms and, without a lab test; it was impossible to identify the source. As a result, it is necessary to prescribe several different antibiotics to fight several types of infection. This returns me to my point made above about the over prescription of antibiotics. The doctor did not seem to see any danger in prescribing this many antibiotics to one patient.
            My experiences thus far in both Serowe and Gaborone have been invaluable. Through these, I have come to a better understanding of healthcare in Botswana, as well as how the HIV pandemic is being treated in one of its hottest spots in the world. Learning about treatment and the nature of HIV in this country provides a giant window into this disease, which has devastated countless people’s lives all over the world in such a short period of time. Beyond this, I have also been able to reflect on the nature of medicine, and my own desire to pursue a career, and life in medicine. My conviction that this is the proper course for me has never been stronger. 

No comments:

Post a Comment