View from the ground, by Dr Kim Grant
How could working in a remote hospital in Africa possibly be at all relevant to being a GP in the UK? This is what I asked myself when I embarked on a year working in a rural, understaffed hospital in the deprived former Transkei area of South Africa. It formed part of my London GP training scheme in an innovative pilot back in 2009.
At the time I thought that all my learning would be about HIV, TB, malnutrition, gunshot wounds, chest drains, and emergency obstetrics. I certainly saw an abundance of pathology and clinical signs, and was given hefty responsibility. But as I reflect several years later, now working in the not-so-deprived city of Edinburgh, I realise that I also learnt plenty of non-clinical lessons. I could wax lyrical for hours about my time there but I will try to touch on a few themes instead.
Health beliefs certainly differ in South Africa. Sangomas (traditional healers) would attempt to ‘draw out’ illness by making multiple cuts over the bodies of little babies, leaving them looking like hedgehogs with cuts across their backs. I also came across a child with conjunctival gonococcal infection. It transpired that his mother thought that urine was a good thing to clean her toddler’s eye with. Then again, we have all sorts of old wives’ tales around health in the UK: feed a cold, starve a fever; don’t go outside with wet hair or you’ll catch a cold. Many of our patients take herbal medications—something that’s always worth remembering when you see abnormal liver function tests. And of course the UK is very much a melting pot of cultures, each with their own health beliefs.
I have also learnt the importance of checking patient compliance whatever environment you work in. An elderly gentleman in London saw me dutifully every month with uncontrolled hypertension. Although I escalated his blood pressure medication, his hypertension stubbornly persisted, even on 24-hour home monitoring. That was until one day when I asked gently about whether he actually took any of the tablets. Nope, not one, he just liked the company of coming to see the doctor once a month! We focused on his isolation and mood from that day on. This case mirrors that of an elderly South African man with a version of COPD, likely caused by chronic smoke exposure from the cooking fires in his rondavel (round mud hut). He was on various inhalers but his shortness of breath was not improving. I asked him to show me how he used the inhaler—I had to keep a straight face as he scooshed his salbutamol aerosol directly into his left eye then looked hopefully at me. Needless to say, things improved once we honed that inhaler technique!
I recall seeing a 65-year-old male in South Africa in the outpatient department, which served as an A&E, general practice, and everything in between. He really needed admission as he was septic with likely pneumonia and HIV to boot; however, he refused admission for IV antibiotics. My GP mode kicked in and I asked the translator to ask what he was worried about. It transpired that his horse, which he had journeyed on since sunrise, was tied up outside the hospital and there was no one who could look after it! Okay, so I don’t have any patients who ride horseback to my surgery in Edinburgh, but it does remind me of a similar UK case where an elderly lady was refusing necessary admission all because she had a wee dog she needed to care for. Both act as excellent reminders of why it is important to explore patients’ concerns.
‘Sundowners’ are a wonderful South African tradition, which involve a cold beer with colleagues on the beach, watching the sunset after a long day at work. A debrief, a period of mindfulness, down time after a hard day. I occasionally do something similar here in the UK once the kids are in bed; sitting in our back garden, usually with a brolly up (I suppose in Scotland they’d have to be called ‘raindowners’ instead)! But there are always holidays to recreate the sundowner tradition, minus the stressful day part of course.