This is a reflection on an experience I had some time ago in its raw, non-edited form. It shows a bit of what the student life is and the little joys we get from it.
There was a smile on the mother’s face as we left the room. I had been in there with my fellow second year student as part of our pediatric session for the Patient-Doctor experience (PD) and he had happened to be the last patient we saw that day.
I must first admit that I have been on e of the many students that have smirked in disdain as our preceptors tried again and again to justify the saying of catch phrases like “that must have been hard for you” to patients. I understood the need for empathy towards the patient but I also knew the patient’s primary goal was to get treated. And as a second year, my aim was to learn the ropes for survival during third year and that involved learning about diseases, procedures and doctor preferences.
The morning was rather slow this Wednesday and we saw about two patients, one very quiet and needing little persuasion to consent to procedures, the other hyper-excitable and having more fun in a hospital than I had ever seen anyone have. In both rooms, I played the game of peek-a-boo while the physician and or resident got what they needed for diagnosis from child and mother alike. In the room of the third patient, we morphed from clowns into strong men holding down a child as a venous line was placed in her vein to hydrate and nourish her. I was learning. My day was getting productive but not as productive as it would in the next few hours.
My colleague and I had been discussing how best to get out early from the rather quiet ED (emergency department) to study for the STEP I exams when the cardiac monitor started screaming in protest. The beeps got louder and the rush of footsteps past the staff room indicated a major event was happening. Before we could rush into the room, the door was closed and we were left to rue a missed opportunity.
SVT, I heard them say. And with that I went to the still complaining monitors to conduct my personal consult. It was no SVT since there was no sinus rhythm but there was tarchycardia alright, 240 beats per minute in a child and all I could think of was what a unique opportunity this was to see theory in practice. The loud cries coming from Room 3 blended into one with the beeping of the monitor in front of me and both played in sync with the ups and downs of the EKG baseline and the cluttering and smoothening of the rhythm strip as I stood intently looking for the P wave before the QRS complex and arguing with my colleague about whether the initial upstroke was the P or whether there was a bundle branch block.
Finally, we got our chance or let me say, I got my chance when the cardiologist was brought down for adenosine therapy and my colleague volunteered to interpret the Arabic that the mother spoke. I saw a little boy in obvious pain with his face buried in his mother’s bosom and the hand he could use digging into the winter coat that she apparently was oblivious to the fact she was still wearing. And in the eyes of the mother, I saw not just pain and despair, but confusion—confusion about what was going on and probably confusion from being listening to what was being discussed around her and not understanding a single word of it.
We took our positions in the far corner of the room out of the way of the hurried masses and looked on silently while the professionals went about their work. I attempted my game of peek-a-boo again but where it held the first patients attention throughout our visit to her room, it caught this one’s only for a second. I watched my colleague communicate the findings and plans to the mother and repeat her questions and consents to the attending. I did not comprehend what they said to each other but from her mannerism, she seemed to trust in what the doctors were doing and only wanted her son to be free from suffering. First, a bolus of Midazolam was administered to calm the still remonstrating child and then preparations were made to administer adenosine in the hopes of getting him out of his arrhythmia. With each dose, he looked on first in calm and then as the medicine made its way to his heart he would writhe in pain and attempt to reach for his mother who stood holding his hands and brushing his hair with the other while tears run from both eyes. I turned and whispered to my friend to tell her everything would be okay, to “do what we are told to do in PD” but he was an interpreter. Was it really his place to do that? I was of course still jesting and I was still wracking my brains on what the mechanisms of action of adenosine and midazolam were but there was something else dawning on me that many hours in my PD lectures had not convinced me about—these two people were concerned not only about the treatment being administered. They wanted hope against hope that everything would be fine.
The adenosine intervention ultimately failed and the patient had to be transferred to the surgical intensive care unit. While preparations were being made for this and an ultrasound was sought to observe heart structure and function, there was a temporary lull in affairs and I went over to hold the boy’s hand. He held my finger tightly while I said to him that he was going to be fine without knowing whether he understood me and praying that he would be alright. We stood there silently watching each other and saying nothing more but understanding that a connection had being made that was essential to the humanity of both of us. The ultrasound came and left without him letting go of my finger and another cardiologist who could speak Arabic came and left and he would still not let go of my finger. Finally, at 5:30pm, 30 minutes past our check out time and with every thought of studying for the upcoming boards out of my mind and concerns about p-waves and inverted t-waves nowhere near the forefront of my consciousness, I was able to extricate my hand and mumble a good luck to the mother. At the door, I turned and waved. Bye S., I said. With the IV lines still in place and the EKG leads hanging off his chest, he turned to look at me, raised his hand slightly off the bed, and waved in return. At that moment, a lightness descended on me and for the first time that late afternoon, I saw a smile in the mother’s eyes and about her lips. Then I realized I was smiling as well.
On my way out of the ED, I could hear the cardiac monitor still shouting its revelations to anyone that would listen. But in Room 3, a silence had descended; a brief respite from what would most likely be another frantic few hours.
Prime
*************************************************
This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
*************************************************
Saturday, August 29, 2009
Friday, July 31, 2009
Brain Drain -- A Dead Hero or A Live Coward
I recently watched Public Enemies, the "autobiography" of John Dillinger, that most inglorious American robber of the yesteryears. In one scene, a bank manager attempted to delay the inevitable by fiddling with his keys. Dillinger smacked him upside of the head and said matter of factly, "you can be a dead hero or a live coward". The words if ever spoken by the man, most likely, did not start with Johnny and they hold meaning for more than that banker. I thought, "surely, this is no different from the choice faced by every migrating Ghanaian doctor". But is it?
According to a Ghana Ministry of Health report, there were on average (median) 3 doctors and 35 nurses per 100,000 people in the country in 2005. That made a total of 1241 physicians and 6599 nurses in a country of more than 20 million people. There were also 791 Ghanaian trained doctors practising in countries outside Ghana (NEJM 2005;353:1810-8) and that's only those trained in Ghana. The numbers were better in 2007 with reports of 13 doctors and 92 nurses per 100,000 (NEJM 2007;356:440-3). So we have advanced a bit yes? But why exactly do physicians, with a sworn oath to serve mankind leave the hallowed shores of Chorkor and Cape Three Points for the white man's land? The reasons may surprise you.
We'll start with the obvious one -- money. See there is more money to be made in the US and UK as a health professional than in Ghana. Given the current rate of production of doctors in the US lags quite far behind the ever increasing need for them, there will always be the demand for doctors from other countries. So how much, exactly, is the Ghanaian doctor making? The statistics, as they usually are from developing nations, are murky at the least and depends on who you ask. The only information I found after scouring the web is found here. A house officer, the equivalent of a resident apparently made $700/700 cedis per month in 2007 if we are to take the word of the doctors. That's half the income an undergraduate investment bank intern makes in per week in the US. Compare this to how much a community activist turned Member of Parliament makes and you can understand the agitation of the incessantly striking doctors back home.
In a country where a plate of Selsbridge fried rice cost in the range of 4 cedis the last time I checked and does not satiate me, a man's could run through that much in ehhh, 2 months. Now let's add a wife and 2 kids and we are coming down to less than a month. And you say, the average man eats kenkey anyways so why shouldn't the doctor? You are indeed right. Include this factor, rent, utilities, count the number of extended family members our young doctor must support in addition to the mother who broke her back for him to go to school and he saves maybe 150 cedis at the outside ceteris paribus. The average income of a medical resident in the partners medical system in Boston, MA, was about $50,000 annually as of '07. That's before taxes of course, rent is much higher than in Ghana at close to $1,500 depending on where you live, average meal costs $8 so no you are not living like a king/queen. But you are living. And your dollars would go a longer way in Ghana -- or used to. So, would you rather live in Ghana and make the meager income, serving your healthcare deprived people or would you rather migrate out to serve the healthcare deprived people of the US and make much more? At least that used to be the question.
Recently, a different generation of doctors have arisen, driven by a patriotic zeal to serve their country but still, looking for the way out. Why? I had a rather disturbing facebook conversation with one of my high school mates recently. He is currently a student at the University of Ghana Medical School. He, see, was in the US on an exchange program and was looking to return for medical school and eventually, work. Why, I asked, are you, a Ghanaian, trained on my mother's tax income thinking of leaving the country when my retired mother is back there? Who will deal with her medical issues? Where is the return on her investment? The government says pay a fine if you leave immediately after training but will the fine treat her if she falls sick? I was of course not talking to someone without family in the country. He gave me a laundry list of reasons why he could not stay in the country. But before that, he summed it up in one word -- Indiscipline.
According to him, there isn't only lack of equipment with which to deliver the needed care but the available ones frequently break down and are usually not fixed. Working conditions, described as hours, available nurses, are terrible and the bureaucracy associated with the teaching and delivery of the arts and science of medicine is legendary. Add into this the general laisssez faire approach of Ghanaians and the concept of African time (Case in point, months after I'd liaised with a group of philanthropists in Boston to send books to the UGMS, I am still waiting for the reply from a vice dean of the school on whether the delivered books have been claimed from the harbour) and you get the frustrations of an idealistic young man who went into the profession with the fire and brimstone spewing prophecies of a doomsday preacher only to crash with disillusion. Of course included in those ideals is the promise of riches but one cannot deny the inherent good in him. I, as expected, berated him for expecting someone else to fix his country while he leaves to prosper in another's. He was not patriotic, I said. I, I boasted, am going back to fix the country and my education was not even subsidized by the government. But is he any less patriotic than I? Am I any better for going back? Until systemic changes are made and political will for He definitely would not be a hero for staying home. It is expected that he stays. But is he a coward for leaving? I think not.
In the following posts, look out for my thoughts on the immigrant physician-trainee experience and the generational movement with every intention of going home to help change and make a living in Ghana.
Prime
*************************************************
This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
*************************************************
According to a Ghana Ministry of Health report, there were on average (median) 3 doctors and 35 nurses per 100,000 people in the country in 2005. That made a total of 1241 physicians and 6599 nurses in a country of more than 20 million people. There were also 791 Ghanaian trained doctors practising in countries outside Ghana (NEJM 2005;353:1810-8) and that's only those trained in Ghana. The numbers were better in 2007 with reports of 13 doctors and 92 nurses per 100,000 (NEJM 2007;356:440-3). So we have advanced a bit yes? But why exactly do physicians, with a sworn oath to serve mankind leave the hallowed shores of Chorkor and Cape Three Points for the white man's land? The reasons may surprise you.
We'll start with the obvious one -- money. See there is more money to be made in the US and UK as a health professional than in Ghana. Given the current rate of production of doctors in the US lags quite far behind the ever increasing need for them, there will always be the demand for doctors from other countries. So how much, exactly, is the Ghanaian doctor making? The statistics, as they usually are from developing nations, are murky at the least and depends on who you ask. The only information I found after scouring the web is found here. A house officer, the equivalent of a resident apparently made $700/700 cedis per month in 2007 if we are to take the word of the doctors. That's half the income an undergraduate investment bank intern makes in per week in the US. Compare this to how much a community activist turned Member of Parliament makes and you can understand the agitation of the incessantly striking doctors back home.
In a country where a plate of Selsbridge fried rice cost in the range of 4 cedis the last time I checked and does not satiate me, a man's could run through that much in ehhh, 2 months. Now let's add a wife and 2 kids and we are coming down to less than a month. And you say, the average man eats kenkey anyways so why shouldn't the doctor? You are indeed right. Include this factor, rent, utilities, count the number of extended family members our young doctor must support in addition to the mother who broke her back for him to go to school and he saves maybe 150 cedis at the outside ceteris paribus. The average income of a medical resident in the partners medical system in Boston, MA, was about $50,000 annually as of '07. That's before taxes of course, rent is much higher than in Ghana at close to $1,500 depending on where you live, average meal costs $8 so no you are not living like a king/queen. But you are living. And your dollars would go a longer way in Ghana -- or used to. So, would you rather live in Ghana and make the meager income, serving your healthcare deprived people or would you rather migrate out to serve the healthcare deprived people of the US and make much more? At least that used to be the question.
Recently, a different generation of doctors have arisen, driven by a patriotic zeal to serve their country but still, looking for the way out. Why? I had a rather disturbing facebook conversation with one of my high school mates recently. He is currently a student at the University of Ghana Medical School. He, see, was in the US on an exchange program and was looking to return for medical school and eventually, work. Why, I asked, are you, a Ghanaian, trained on my mother's tax income thinking of leaving the country when my retired mother is back there? Who will deal with her medical issues? Where is the return on her investment? The government says pay a fine if you leave immediately after training but will the fine treat her if she falls sick? I was of course not talking to someone without family in the country. He gave me a laundry list of reasons why he could not stay in the country. But before that, he summed it up in one word -- Indiscipline.
According to him, there isn't only lack of equipment with which to deliver the needed care but the available ones frequently break down and are usually not fixed. Working conditions, described as hours, available nurses, are terrible and the bureaucracy associated with the teaching and delivery of the arts and science of medicine is legendary. Add into this the general laisssez faire approach of Ghanaians and the concept of African time (Case in point, months after I'd liaised with a group of philanthropists in Boston to send books to the UGMS, I am still waiting for the reply from a vice dean of the school on whether the delivered books have been claimed from the harbour) and you get the frustrations of an idealistic young man who went into the profession with the fire and brimstone spewing prophecies of a doomsday preacher only to crash with disillusion. Of course included in those ideals is the promise of riches but one cannot deny the inherent good in him. I, as expected, berated him for expecting someone else to fix his country while he leaves to prosper in another's. He was not patriotic, I said. I, I boasted, am going back to fix the country and my education was not even subsidized by the government. But is he any less patriotic than I? Am I any better for going back? Until systemic changes are made and political will for He definitely would not be a hero for staying home. It is expected that he stays. But is he a coward for leaving? I think not.
In the following posts, look out for my thoughts on the immigrant physician-trainee experience and the generational movement with every intention of going home to help change and make a living in Ghana.
Prime
*************************************************
This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
*************************************************
Saturday, July 25, 2009
Barcamp09 -- Healthcare Ghana
It is fitting that the first post on this blog is from Barcamp09. Barcamp is a coming together of young Africans in the diaspora. It encompasses multiple brainstorming sessions on a myriad of issues that are pseudo-generated on the go. I just left one such breakout session on the nature of the healthcare system in Ghana. As is usual at these things, there was a lot of talk about the problems and a lot of finger pointing to lack of political will. However, there were multiple pearls of solid solutions in the rubble. From teleconferencing to mobile vans to setting up a fund for contributions from Ghanaians in the diaspora and at home, we are beginning to think of effective ways to fill the gaps in healthcare delivery in our country. A group has been set up that will, through email, continue the efforts thus begun.
If you are out there, if you care, join the cause.
Prime
If you are out there, if you care, join the cause.
Prime
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