This post will be a little longer than usual. If you’re not sure what a full-service family physician can do, this story’s for you.
The following is the body of an email sent by one of our 3rd-year JPS family medicine RESIDENTS about his experiences working at a regional hospital in Tanzania this past month. He is with another of our family medicine 3rd-year residents who are about to graduate from residency, but both of whom will stay at JPS for an extra year of optional training in maternity and global healthcare. I have their permission to post this. Personal identifiers have been removed. This is what he wrote:
They are beginning to ask if this should be called “African Surgical Referral Hospital.” In the last five days we have had:
– Perforated uterus with perforated colon and abscess after D&C at outside facility
– Ruptured ectopic pregnancy
– Bowel obstruction with volvulus of the descending colon
– Perforated uterus with intraabdominal abscess after illegal abortion and D&C at outside facility
– Small bowel obstruction with 12-wk pregnancy, requiring bowel resection
– 4 cesarean deliveries, one for eclampsia
– A multiple trauma MVC roll-over with significant orthopedic injuries
This is in addition to the onslaught of medically complicated patients. Those who have been here before say this summer has been worse than usual. We have 4 children in the hospital right now with severe burns. One, a little boy about 7 years old, has 2nd and 3rd degree burns over 40 percent of his body, including his genitals. It is labor intensive and supply-consuming – not to mention emotionally taxing – to do dressing changes for 4 burn patients every 2-3 days. And any certified burn center would be appalled at the conditions under which these dressing changes must take place. Ketamine has been the saving grace for these children.
As I walked down the sidewalk today I saw one of my patients from our first week here, returning for dressing changes. She had Stevens-Johnson Syndrome due to her Nevirapine which she was taking for HIV/AIDS. She is doing well. We have another patient, about 30 years old, who has been in respiratory distress for 2 days with an initial blood pressure of 240/130, an SpO2 of 84% on 2L, and a chest xray that looked like PCP, but his HIV test was negative. Now he isn’t making urine. We are treating him for the possibility of inhalation anthrax. He is a butcher by trade. We have at least 3 or 4 patients with HIV and TB presently on our inpatient service. A common complaint seems to be GI upset shortly after starting TB meds, and most of these patients concurrently have HIV.
Today I saw a 10-year-old girl that was admitted by another team member yesterday with “weakness.” Her hemoglobin was 3.3. She received one unit of blood, which was her 12th lifetime transfusion. And yesterday was the first time anyone had ever checked her for sickle cell anemia – it was positive. Her mother is a nurse in the pediatric ward here. The patient really perked up after her transfusion. Her grandmother said, “Now she looks black again. Before the blood she looked white (pale).”
It has been a very trying experience, and we have been stretched beyond our limits, but it has also been a rewarding and beneficial experience. I think we have done a lot of good here. We have one more week at the hospital. We covet your prayers and thank you for your support.
Family Medicine Resident
I asked him by email to tell me more about the surgeries, especially who was the primary surgeon. Here is what he wrote:
Perforated Uterus with perforated colon –the otherFM resident assisted the Tanzanian doctor, they closed both perforations and the patient did very well.
Ruptured ectopic – I assisted the Tanzanian doctor. Partial salpingectomy. Patient did fine.
Bowel obstruction with volvulus – OtherFM resident assisted the Tanzanian doctor, partial colectomy with primary anastomosis. Pt did well.
Perforated Uterus with intraabdominal abscess – I assisted Tanzanian doctor. Closed the perforation and washed out abdomen. Pt died on post-op day 1, probably from sepsis.
Small bowel obstruction in pregnancy – I was primary, Other FM resident assisted. We resected 90 cm of small bowel. Pt did well. She was still in the hospital when we left. Last time we checked FHTs was post-op day 3 and the fetus was still alive.
4 c-sections other resident and I did together, alternating Primary/Assist.
There was a total of 27 cesareans in our 4 weeks at the hospital, and I think 8 other laparotomies. We were directly involved in pretty much all of it, and we were the ones primarily taking care of them post-operatively. Everyone we operated on unquestionably needed surgery, and probably would have died without intervention. All of these surgeries were done under Ketamine. No spinals. No inhaled anesthesia.
I have some pictures I can share when we return.
I guess in the spirit of not revealing patient or physician identities, I can’t share the pictures later.
I acknowledge that there are just a few family medicine residencies like JPS left in the U.S. that can still train young family physicians to have such an extensive set of skills, and that most U.S. family physicians can’t provide a similar breadth of services. However, I’m sure that no internal medicine or pediatric residents, nor essentially no practicing internist or pediatric physicians, could provide this breadth of services.
In this post, I’m not advocating that U.S. family physicians be encouraged to provide these services here – for a variety of cultural, practical, and medical-legal reasons. And clearly, local Tanzanian physician resources were present to help these residents with their work, though many U.S. rural family physicians provide services similar to these examples.
However, I am saying that these young residents demonstrate the inherent efficiency of family physicians. Beside these care experiences, they worked in clinics seeing all ages of patients, including prenatal care, who presented with any concern an undifferentiated patient population can have.
Imagine this same environment covered by the siloed multi-physician Mr. Potato Head™ medical world of the U.S., especially the northeastern U.S. seaboard (the hotbed of anti-family medicine bigotry). To replace these two family physicians, here is what you’d need just to cover the stories posted here:
Pediatricians
Internists
Geriatricians
Emergency physicians
Hospitalists
Infectious diseases
Pulmonologists
Nephrologists
Gastroenterologists
Obstetricians
MFM high-risk obstetricians
Orthopedists
Trauma surgeons
Burn surgeons
General surgeons (the residents resected the damaged colon on their own)
Pediatric urologists
Pediatric hematologists
Intensivists
Anesthesiologists perhaps (not sure who directed the ketamine administration in Africa)
General radiologists
Ultrasound radiologists (for prenatal care and ER sonograms)
The magic of family physicians to deliver better health at a lower cost comes not from EMRs, care coordinators (as most are currently used), team-based care, or prevention. The magic comes in part from the breadth of services they can provide in a one-stop shopping experience for patients, plus a series of attitudes, beliefs, and skills unique to family medicine.
I am so proud of these two intelligent committed family physicians who became physicians for all the right reasons. Every now and then people ask me why I stay as a teacher in a family medicine residency in a county hospital. The fact that I had even a tiny bit to do with their ability to provide this care is one of the many reasons why.
On the other hand, after reading this story, I bet I didn’t have to tell you that.
Bravo! Bravo to the JPS Family Medicine Residency, to the teachers there and to the professionalism and humanitarian qualities of these two young doctors. Not only do they have the professional skills acquired in a terrific teaching setting, but they have the confidence to wade into a M*A*S*H setting to deliver care under what must be unimaginably challenging circumstances.
This underscores a point I have been making in many writings and communications to the outside world. A Family Physician has the breadth of knowledge to handle many tasks that they must now send out because they are so undervalued when it comes time to simply allow them to do what they are so well-suited to do. If we EVER get smart about our family medicine resources, we will recognize the great strides we can take in controlling health care costs by simply paying them for what they can do. It’s so often misconstrued that what family physicians and other quality (true) primary care doctors are saying is whining to get more money – when it’s really a matter of just paying them for what they can so effectively provide in a comprehensive range of their skillsets.
Not in Jefferson county! In resident 20 years ago I had to beg to get to do anything. It was even hard to assist in surgery because the scrub techs did nit want me doing their job. The most exciting time in my medical career was medical school and residency but I like my chronic patients and limited excitement any day.