It's disconcertingly quiet for a Saturday morning. On my morning run, and then on my walk up to the Umubano Hotel pastry shop for a special breakfast treat, I passed almost nobody. The occasional moto (a motorcycle taxi) zipping by, a bus here and there, a few pedestrians strolling. It almost feels like the middle of the night. But actually, today is the last Saturday of the month, which means it's umuganda, community service day. This is a mandatory, nationally mandated day of service every month. Everyone who can, from 8 am until 11 am, is required to participate, helping to pave roads, pick up garbage, trim grass and bushes, repair public facilities and such. A pretty amazing concept. Another example of the shared responsibility that is felt here, toward continually making Rwanda a greater place.
I compare this concept of umuganda, with my feelings about this past week of work at the hospital. I'm still absorbing it all. For me, this week has been about figuring out my role, understanding the strengths and weaknesses of the healthcare system here, and majorly resetting my expectations. Many people have told me that the health system and hospitals here are quite good, compared with other places in Africa. I'm having a hard time seeing that, but I have stop comparing it to anything that I'm used to at home. Being the largest referral center in Rwanda does mean anything in the context of western medicine. From my work in Zambia, I had a pretty good understanding of what outpatient medicine is like in developing countries, but it still didn't prepare me for what it would be like on the inpatient side.
I wrote earlier this week about the woman who died because her family had to keep going out to the pharmacy to buy her medications she needed. The same is true of almost everything in the hospital. Each patient has their own bag of supplies they must buy - bandaging supplies, IV lines, IV fluids, gloves. If they run out, well, better hope somebody else on the ward is willing to share. Yesterday a woman started oozing blood out of some sutures she had from her surgery, in a matter of hours soaking completely through the bandages and sheets. We had to walk around the room, asking the other other patients if we could use some of their tape, some of their gauze, to redress her wound. Diagnostic tests must also be prepaid. We may spend hours on morning rounds discussing a patient's presentation, differential diagnosis and workup that must be done. We write "Chest CT scan" in the progress note, and then write an order for it. But that CT chest won't actually get scheduled until the patient's family takes that order, brings it to the cashier to pay, and then brings back the stamped receipt. And if they can't pay, there are social workers to help, with some kind of collective pot, but it's unclear how much and who can get funds from that. And even then, it may not be scheduled for over a week, even for an inpatient. Yesterday we had our medicine attending call his radiology attending buddy, who agreed to reschedule a chest CT for our patient for next Tuesday instead of next Friday, while she has already been in the hospital for over a week, and wants nothing more than to get back to her nine month old child at home.
Physicians, and actually, entire health systems here, hardly have any responsibilities over the weekends. In fact, think of Friday as a half day, even at the hospital, for Friday afternoon is actually a national sport day. Think intramural soccer, doctors versus teachers. When I asked who would be taking care of our ward over this weekend, following up on all these plans we made, the answer was essentially nobody. Just like the night coverage resident, there will be one, perhaps two residents in the hospital to cover all of the wards over the weekend, who have received no formal signout on any of them. But no formal rounding, no new plans, no followup on old plans. They are only there to deal with emergencies with the patients, when the nurses decide to call them. Every order we wrote yesterday had to be clear about its relevance to the entire weekend. IV fluids? Let's hope that even some of our malnourished, hypotensive patients are still on IV fluids when we get back on Monday. I've heard people say patients are lucky to survive through the weekend, and if they can, then they must be doing pretty well. So much for Press Ganey scores.
Never again will I complain at Yale about a particular radiology study that cannot be done over the weekend, that must wait until Monday. At least it can be done on Monday. At least there are still many doctors in the hospital over the weekend, keeping that patient stable, caring for them, until further diagnostics can be done. Never again will I complain about being on call over the weekend, or responding to a code in the middle of the night, because I am doing my part, my duty as a physician, of patient care. So many things that have become so routine in our care of patients at home: our team structure as medical students, residents and attendings, that goes along with our well defined responsibilities and expectations, with accountability, our handoffs to each other of patient information, all of these things do not yet exist here, at least not officially, not entirely, not solidly. There is no such thing as patient signout. You're done with your work for the day? You disappear. The one night coverage resident is not told a thing about the patients on the wards. If there is a problem, they will try to deal with it. And then won't tell anybody about it in the morning, except in the form of an illegible note in the patient chart. Maybe.
Let me take a step back here. Many of the Rwandan doctors I have met so far, attendings and residents alike, have been excellent. Their knowledge is solid and extensive. Their commitment to teaching is obvious, in the time spent every day teaching students and residents. The attendings demand near perfection in terms of instant ability to regurgitate not only differential diagnoses of symptoms but also medication doses and physiological formulas. Their practical skills are excellent and extensive too, as most medical students are required to work for a couple of years before returning to residency. Many of the residents here have done their share of surgeries, from lymph node biopsies to c-sections, before ever starting their medicine residency. But that's just one part of the equation. The resources, and the overall medical culture are key components too. You can be the most well meaning physician, who may feel it essential to have weekend rounds. But if no other hospital services are available that day, it severely limits how much you can do.
There's a new initiative here, called HRH, which is trying to slowly address all these issues. Over the course of years, their goal is to twin US doctors, nurses and hospital admin staff with locals in the same role, to slowly improve hospitals and physician training here. After three weeks here, I think this is an amazing and awesome challenge. I think Rwanda is up for it. The pieces are there. But it's gonna be a while.
In the mean time though, what is my role? If I try to be the type a, controlling, a little OCD, organized resident that I'm used to being, I'm just going to burn myself out. A weeks worth of checklists did me no good, because trying to review those checklists with the team after rounds, or really, really being sure that those things have actually gotten done, just doesn't happen very well. Not all the time. Orders get forgotten or lost. Or they remain as an unpaid sheet of paper by the patient's bed. How about solidifying team structure. You! Lowest medical student on the team, this is your role! This is what I expect of you! But if they decide to leave after rounds without helping implement the day's plans, what can I do? I can't change a whole culture in the few weeks I'm here. So that leaves teaching. In some in-between land between being a resident, and being an attending, that leaves me, teaching what tidbits I can, imparting what sense of patient duty and team structure and note writing I can. And definitely learning a whole bunch about diseases I don't see often or ever at home.
Hopefully, I can return to Rwanda in ten years, and see the fruits of all these efforts. That sense of duty about umuganda, extending truly and deeply into the healthcare culture as well. As one of my attendings says now to the Rwandan residents, when talking about our young patients on the ward, "these patients are the future of Rwanda, take care of them." Hopefully this will become a system in which we truly can.
I compare this concept of umuganda, with my feelings about this past week of work at the hospital. I'm still absorbing it all. For me, this week has been about figuring out my role, understanding the strengths and weaknesses of the healthcare system here, and majorly resetting my expectations. Many people have told me that the health system and hospitals here are quite good, compared with other places in Africa. I'm having a hard time seeing that, but I have stop comparing it to anything that I'm used to at home. Being the largest referral center in Rwanda does mean anything in the context of western medicine. From my work in Zambia, I had a pretty good understanding of what outpatient medicine is like in developing countries, but it still didn't prepare me for what it would be like on the inpatient side.
I wrote earlier this week about the woman who died because her family had to keep going out to the pharmacy to buy her medications she needed. The same is true of almost everything in the hospital. Each patient has their own bag of supplies they must buy - bandaging supplies, IV lines, IV fluids, gloves. If they run out, well, better hope somebody else on the ward is willing to share. Yesterday a woman started oozing blood out of some sutures she had from her surgery, in a matter of hours soaking completely through the bandages and sheets. We had to walk around the room, asking the other other patients if we could use some of their tape, some of their gauze, to redress her wound. Diagnostic tests must also be prepaid. We may spend hours on morning rounds discussing a patient's presentation, differential diagnosis and workup that must be done. We write "Chest CT scan" in the progress note, and then write an order for it. But that CT chest won't actually get scheduled until the patient's family takes that order, brings it to the cashier to pay, and then brings back the stamped receipt. And if they can't pay, there are social workers to help, with some kind of collective pot, but it's unclear how much and who can get funds from that. And even then, it may not be scheduled for over a week, even for an inpatient. Yesterday we had our medicine attending call his radiology attending buddy, who agreed to reschedule a chest CT for our patient for next Tuesday instead of next Friday, while she has already been in the hospital for over a week, and wants nothing more than to get back to her nine month old child at home.
Physicians, and actually, entire health systems here, hardly have any responsibilities over the weekends. In fact, think of Friday as a half day, even at the hospital, for Friday afternoon is actually a national sport day. Think intramural soccer, doctors versus teachers. When I asked who would be taking care of our ward over this weekend, following up on all these plans we made, the answer was essentially nobody. Just like the night coverage resident, there will be one, perhaps two residents in the hospital to cover all of the wards over the weekend, who have received no formal signout on any of them. But no formal rounding, no new plans, no followup on old plans. They are only there to deal with emergencies with the patients, when the nurses decide to call them. Every order we wrote yesterday had to be clear about its relevance to the entire weekend. IV fluids? Let's hope that even some of our malnourished, hypotensive patients are still on IV fluids when we get back on Monday. I've heard people say patients are lucky to survive through the weekend, and if they can, then they must be doing pretty well. So much for Press Ganey scores.
Never again will I complain at Yale about a particular radiology study that cannot be done over the weekend, that must wait until Monday. At least it can be done on Monday. At least there are still many doctors in the hospital over the weekend, keeping that patient stable, caring for them, until further diagnostics can be done. Never again will I complain about being on call over the weekend, or responding to a code in the middle of the night, because I am doing my part, my duty as a physician, of patient care. So many things that have become so routine in our care of patients at home: our team structure as medical students, residents and attendings, that goes along with our well defined responsibilities and expectations, with accountability, our handoffs to each other of patient information, all of these things do not yet exist here, at least not officially, not entirely, not solidly. There is no such thing as patient signout. You're done with your work for the day? You disappear. The one night coverage resident is not told a thing about the patients on the wards. If there is a problem, they will try to deal with it. And then won't tell anybody about it in the morning, except in the form of an illegible note in the patient chart. Maybe.
Let me take a step back here. Many of the Rwandan doctors I have met so far, attendings and residents alike, have been excellent. Their knowledge is solid and extensive. Their commitment to teaching is obvious, in the time spent every day teaching students and residents. The attendings demand near perfection in terms of instant ability to regurgitate not only differential diagnoses of symptoms but also medication doses and physiological formulas. Their practical skills are excellent and extensive too, as most medical students are required to work for a couple of years before returning to residency. Many of the residents here have done their share of surgeries, from lymph node biopsies to c-sections, before ever starting their medicine residency. But that's just one part of the equation. The resources, and the overall medical culture are key components too. You can be the most well meaning physician, who may feel it essential to have weekend rounds. But if no other hospital services are available that day, it severely limits how much you can do.
There's a new initiative here, called HRH, which is trying to slowly address all these issues. Over the course of years, their goal is to twin US doctors, nurses and hospital admin staff with locals in the same role, to slowly improve hospitals and physician training here. After three weeks here, I think this is an amazing and awesome challenge. I think Rwanda is up for it. The pieces are there. But it's gonna be a while.
In the mean time though, what is my role? If I try to be the type a, controlling, a little OCD, organized resident that I'm used to being, I'm just going to burn myself out. A weeks worth of checklists did me no good, because trying to review those checklists with the team after rounds, or really, really being sure that those things have actually gotten done, just doesn't happen very well. Not all the time. Orders get forgotten or lost. Or they remain as an unpaid sheet of paper by the patient's bed. How about solidifying team structure. You! Lowest medical student on the team, this is your role! This is what I expect of you! But if they decide to leave after rounds without helping implement the day's plans, what can I do? I can't change a whole culture in the few weeks I'm here. So that leaves teaching. In some in-between land between being a resident, and being an attending, that leaves me, teaching what tidbits I can, imparting what sense of patient duty and team structure and note writing I can. And definitely learning a whole bunch about diseases I don't see often or ever at home.
Hopefully, I can return to Rwanda in ten years, and see the fruits of all these efforts. That sense of duty about umuganda, extending truly and deeply into the healthcare culture as well. As one of my attendings says now to the Rwandan residents, when talking about our young patients on the ward, "these patients are the future of Rwanda, take care of them." Hopefully this will become a system in which we truly can.
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