Tuesday, July 26, 2016

A Drop in the Ocean

Upon waking up on Wednesday mornings, I try not to press the snooze button. It is my neurology outpatient clinic day at the University Teaching Hospital and the first patients start arriving at 5 AM. Most patients live in the greater Lusaka area but there are always a few who have traveled hours by bus, sometimes overnight. If I can see my first patient by 6:45 AM then I can keep up with the flow. However, if I begin some time after 7 AM then the patient files start to build up and I feel like I am sprinting.

As I walk through the doors of Clinic 4, there is already a group of patients seated at the benches. I always try to acknowledge the crowd with the standard Nyanja morning greeting, “Mwa-uka bwanj?”. Its literal translation is “How did you wake?”. Without fail, the tired faces turn to smiles as they appreciate my attempt to use the local language. I get the standard reply “Bwino” (Good) from the crowd. The hour-long Nyanja lessons that my wife and I take on Sunday afternoons with a Peace Corps language instructor has to be one of the best investments that we have made. The nurse, Sister Gloria, who is the matriarch of the clinic, always gives me a knowing smile when she hears my Nyanja as it was upon her insistence that I formally greet all the patients.

I am always at battle with the pink colored patient files. If I have some visiting neurologists, usually from the States or Europe, then I don’t get too upset with the height of the pile. If I am alone, then a large pile can mean that patients at the bottom will be waiting for hours. I try to see the follow-ups first as they are usually more straightforward: a well controlled epileptic in need of a medication refill or a recovering stroke patient requiring a physical therapy referral. However, the clinic is first come first serve so it never quite works out as planned. Inevitably, I will have new patient evaluation that will require as much time as I can provide. A typical example might be a newly diagnosed HIV-infected patient with the inability to walk. In the States this patient would get an hour-long evaluation, subspecialist referral, and perhaps even a presentation in a multidisciplinary conference. I am still grateful that I can give 30 minutes.

Normally, I have finished seeing the last patient by noon. I diligently record every patient I see in an excel file. I am always amazed at how predictable the numbers are in terms of new patients, no shows, and drop ins. As a result, I have learned what I can handle in terms of efficiency. On my average clinic day, there will be 11 follow-ups, 7 news, 6 no shows, and 2 drop ins.  The prevalence of HIV-infected patients is equally predictable. No matter if I audit my files over 3, 6, or 9 months, it is always 18%. Scheduling appointments in time blocks has essentially been proven not to work in this setting as it would require a complete shift in the Zambian concept of time. As my language instructor once told me, “Americans think time can be lost, Zambians think time can be recovered”.

I could see patients every single day and it would still not make a dent in the overall neurological disease burden. I have two other colleagues, also expats, who make up our small neurological community. There are limits to what three providers can do when you are talking about a population of 13,000,000 people.  Hopefully, we make a difference for the patients we see. Our most effective role is training frontiline providers on common neurological conditions.  The holy grail is to train a cadre of Zambian neurologists to take our place and build a meaningful and vibrant neurological community. Until then, our clinical contributions are just a drop in the ocean.

“Do you ever get frustrated?” I received this question recently at a fundraiser in New York City. It was such a simple question but a great one.  I had never formally thought about it and I really had to think hard about the answer. Yes, I get frustrated all the time: power outages, medication non-adherence, bureaucracy, and theft. However, most people working in resource-limited settings are aware of these challenges going in. Also, when something works out despite all these challenges it is incredibly rewardng.  Our EEG laboratory in Clinic 4 is a huge source of pride. It was the first lab of its kind in Zambia, provides a valuable resource to epilepsy patients, resulted in the training of two Zambian EEG technicians, and until a recent economic downturn in Zambia, had been self-sustaining.  I often equate my situation to a coach who has taken over an athletic team full of talent but has never had a winning season. If I can work within the system, motivate the players in the right way, then the wins will start to come.