Where are the Doctors?

by Leana S. Wen, M.D.

Of the 29 graduates of the emergency medicine training program that I�m interviewing here in Cape Town, South Africa, 5 are living and working abroad, in the U.K. and Australia. That may not seem like a lot, but these are already from the select pool of individuals who chose to stay in South Africa for their post-graduate medical training. Many more South Africans leave after medical school to seek higher-paying positions in developed countries.

Why do they do choose to leave? It�s for the same reason that qualified professionals from throughout the developing world leave their home country: to seek better opportunity and better pay. On the individual level, this pursuit it completely understandable. I�m the child of immigrants who came from China to seek a better life; I am only where I am today, a resident physician in the U.S., because of choices my parents made.

On the systems level, the exodus has created health systems that are deficient in doctors, nurses, and other health professionals. When I was in the Congo a few years ago, the going joke was that there were more Congolese doctors in Washington D.C. than there were serving the entire 68-million population of the Democratic Republic of the Congo. The motivations of individual doctors to leave the Congo was very much understandable�the country was in the midst of civil war! But their departure left the country without a functional healthcare system.

The problem of the global brain drain is described in some excellent papers, and Professor Fitzhugh Mullan among others are working on solutions that take into account individual preferences while also building systems solutions. There are two main issues that need to be addressed. Capacity within the developing country needs to be built. We�re talking the basics like security, but also salary needs to be sufficient, and the type of practice needs to be adequately attractive to retain doctors. In South Africa, for example, there need to be enough consultant posts for these EM graduates�otherwise they will go elsewhere to practice the skills that they were trained to do.

There also needs to be policies in place for developed countries to prevent dependence from doctors trained in the developing world. Currently, the U.S. relies on foreign medical graduates to supply its workforce, with 1/3 of all residency spots filled by graduates of non-U.S. medical schools. Foreign graduates have much to offer our country, and yes, the U.S. is also experiencing a workforce shortage. And yes, we do want to provide opportunity for foreign graduates to train and, if they choose, to establish a better life in our country. But we should take care to not have a policy that effectively poaches the few qualified doctors of a developing country whose services are needed far more there. The U.S. (and our partners in the U.K., Australia, Canada, etc) need to develop more training programs to ensure that we adequately provide for our own workforce.

In South Africa, there are two other workforce issues that should resonate with those of us from developed countries as well. The first is that the private sector continues to offer far more lucrative options than the public sector. What can be done to retain the best and brightest to serve the more than 80% of people who rely on public provision of care? The second is the training of other healthcare providers. The vast majority of care in the country takes place in rural settings that are staffed by nurses and mid-level providers. What kind of training can be done to improve the quality of care in these rural areas, and not just in the cities? Other than compulsory service, what can entice qualified doctors to work in these settings?

My final reflection is that almost every single doctor I�ve talked�including the ones who immigrated�genuinely want to be in South Africa. South Africa is home; they want to improve care for their home, their people. Those who left express a lot of regret, and say that they wish the posts were available for them to come back and fill them so that they can continue to improve health care in their country.

My time in South Africa has been invaluable, and I thank the Partners COE for making my trip and this research possible. I look forward to returning. Please send your thoughts and comments on my posts. Thanks for reading. Wen.leana@gmail.com.

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On Race

by Leana S. Wen, M.D.

Mr. A is a 23-year old black man with abdominal pain.

Mrs. S is a 48-year colored woman who was the restrained passenger in a rollover MVC.

Sammy is a 10-year white boy with fever.

OK, maybe it�s just me, but there�s something different about how these medical presentations start. I went to medical school in St. Louis, and once in a while, we did hear of someone referred by race. Maybe someone with sickle cell anemia; maybe someone with a rare inherited disorder. Maybe. But race is a common and almost unavoidable descriptor in South Africa.

And not just in the medical setting. I came to South Africa for the first time about three years ago, and the woman I rented a room from, a lovely Africaans lady in her late-sixties, raved about my �Oriental� skin. Her son was dating a beautiful woman, a �colored� woman. She was also telling me that she and her family were extremely progressive and opposed the apartheid from the beginning, even resigning from the Dutch Reform Church because of its initial position on apartheid. But how could she progressive, I wondered, when she used such terms to describe people?

Race in South Africa is fraught with a troubled past that the country is still grappling with. Under the apartheid regime, race was the sole determinant of what opportunities a person had. Apartheid ended less than twenty years ago, and remains in the consciousness of all but the very young. Interestingly, the way that South Africa has chosen to deal with race is to be completely open about it. Some of my other work was done in Rwanda, where the Rwandan genocide of 1994 is still very much in the public consciousness as well. Rwandans chose the path of not talking about race and who was hutu and who was tutsi. South Africa has taken a very different route by making race front and center of self- and public- identity.

As I came to see, my old landlady was hardly a remnant of some kind of old world tradition. I asked one of the young registrars how I was supposed to identify the consultant, and she directed me to find the �tall colored man�. My fianc� and I were looking for a DJ for our wedding, and the form to fill out asked for basic information: size of event, type of event, type of music requested, age of guests, and� the race of couple and race of guests. My South African fianc� didn�t blink an eye, but my American sensitivities were startled to say the least. Can you imagine such descriptors being used for hiring a DJ in Boston?

So what about this obvious display of race�is it a good thing? I don�t think I understand enough of South Africa to comment. I can say that the people here find the political sensitivity around race in the U.S. in particular but also U.K. and Europe to be excessive. Why not just get it out in the open and obviate passive discrimination, they would say. You�re probably thinking about race anyway. I would argue, though, that my American eyes see race perhaps as being less distinctive and less important of a descriptive. The last ten patients I saw in the U.S., for example, do I really remember them as a black man or a white woman? I�m not sure that I did, but I�m not sure that it would have been a bad thing if I did.

Curious to hear your thoughts, on this and other topics. Please email me, wen.leana@gmail.com.

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Becoming a Doctor in South Africa

Leana S. Wen, M.D.

Greetings from beautiful Cape Town, South Africa!

I am here for the month based out of the University of Cape Town/Stellenbosch University to work on a project examining the perceptions and experiences of the first group of emergency medicine (EM) graduates from the first EM training program in sub-Saharan Africa.

South Africa is a country that�s twice the size of Texas with a population of 50 million. At least 10% of the population subsists on under U.S. $1 a day. At the same time, it is a country where wealthy Europeans come on holiday and buy multi-million dollar vacation homes. In Cape Town, one can go from seeing dozens of the most expensive yachts in the world to tin shacks within a five-minute drive.

Healthcare in South Africa is relatively advanced. It is the training site for doctors from all over Africa; in fact, many American and European medical students come to South Africa to gain trauma and procedural experience. It is also a study of contrast. The private sector that serves less than 20% of the population exhausts over 70% of resources, and it�s possible to receive a very high level of medical service in South Africa. The public sector, on the other hand, is vastly over-burdened, and the lack of resource is most prominently felt in remote rural areas.

The training of doctors follows the UK convention: medical school starts immediately after high school and lasts for six years. Following a one-year internship, new doctors are assigned to do another year of community service, usually in a remote, underserved part of South Africa. This national service model exists in many other countries, and is a powerful way for doctors to give back to their country. It also instills and reinforces the idea of service as being integral to our profession. The U.S. has explored similar service-in-exchange-for-training models, including the novel concept of a national medical school devoted to public health and service to the community. http://www.cogme.gov/18thReport/default.htm. Unfortunately, the idea of compulsory service is not one that has taken hold in capitalist U.S. society.

Most doctors in South Africa practice as general practitioners or non-specialist medical officers. While GPs work exclusively in the primary care setting, medical officers can choose to work on any specialty service. Many graduates enjoy the flexibility of choosing to work in orthopedic surgery for six months, then internal medicine, then anesthesia�. It�s quite a difference from our training system where we choose our specialty while in medical school.

The downside for South African doctors is that for those who wish to specialize in an area, there are few specialty training posts (called registrarships). Also, even after the registrar completes their training, there are problems finding consultant�our equivalent of attending�positions. In my discussions with EM program graduates, the major concern seems to be that after their four years of training, they can�t find EM posts, and as result, have to go back to being a medical officer�the same position they held before their registrarship. Their training and skills are not put to use, and they wonder what is the point of undergoing such a rigorous and difficult training program. It�s a dilemma I�m sure we as US graduates can relate to as well!

I�ll be writing my thoughts on the practice of medicine and specifically EM in a separate post. Until then, stay well, and thanks for reading. Comments welcome at wen.leana@gmail.com.

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Weight Limit

Hasan Merali, MD

Khamer Spirit House

We set off early Tuesday morning for the village of Preambang. The dry season proves to be quite difficult for our ship as the water level is so low. On the way to Preambang the propeller got caught in a fishing net and our captain had to dive in to cut open the net with the kitchen knife. We will likely only be able to use this boat for one more week before having to rent a smaller boat that can handle the shallow water for the remainder of the dry season. Further along in our trip, two men in a fishing boat nearby were frantically waving for us to stop. Thinking that perhaps there was something wrong with the ship that needed immediate attention we cut the engine and waited for them to approach. They were selling shrimp......

In Preambang I saw something completely different....volleyball! There were a few patches of cleared land around the village and some children were having a game. They only have a couple of months of this, however, as soon the water level will rise and completely submerge any bits of usable land they have. There is a spirit house in the middle of the village soaring above all of the other houses. It is at least 12 m high above the water level and in the rainy season the lake will just touch the bottom of it. We spent a day and a half in Preambang seeing patients at the local school. Because of the level of malnutrition Dr. James and I decided to give multivitamins to all of the patients we saw. Unfortunately our supply ran out in the next village but we will be sure to bring more stock next week.

The second village we went to was Maot Khlar. We had been there briefly last week to see a woman with a burn on her hand but this time we came to do a full day clinic for the entire village. There are about 220 families living there. All of the children I see are less than 12 or 13. Anybody older than that is usually working out on the lake for days at a time fishing. The other thing we noticed was that there were very few Vietnamese patients coming to our clinic. When we inquired about this we found out that many of them are worried that they will have to pay money, or that they will have to show some type of registration/immigration card, both of which they do not have. Our captain/cook is Vietnamese and has slowly been working on this problem by trying to educate the Vietnamese people in each village telling them that we do not require any documentation or fees.

The morning was completely peaceful in Moat Khlar while we were seeing patients in the Chief's House (a floating platform with a wall on one side). In the afternoon, however, that all changed. Our director brought over 30 Malaysian Rotary Club members who have been involved in funding various projects in the villages including water filtration devices and schools. They were all eager to get off the boat and see what we were doing. One by one they dismounted their two boats and got onto the platform as it slowly sank lower and lower into the water. Finally, the platform reached its limit and as it touched the water, all of the creatures living happily under the floorboards in the space between the floorboards and the water suddenly emerged. Dozens of cockroaches, mice, and even scorpions suddenly began scurrying all over and onto each of us. I can normally handle these creatures well and they tend not to bother me but as several cockroaches were climbing up my leg, I quickly grabbed a broom and joined a few others in trying to sweep them into the lake. Lesson learned. On a positive note I think there is a good chance TLC will get more funding from the Rotary Club as many of them were in disbelief that this was actually someones home.

On a different note I wanted to write briefly about two other organizations that TLC has partnered with. The first is KIDS International Development Society. They are a Canadian based organization that work in South East Asia and are currently building a floating school for the village of Moat Khlar. It is being constructed in Siem Reap and will be towed to the village once it is complete. The second organization is the Angkor Hospital for Children in Siem Reap. I was fortunate enough to have a tour of this amazing facility a couple of days ago and I was quite impressed. This is where we refer any patients we see in the villages that are sick enough to need inpatient management or further diagnostics. They have a full inpatient unit, an emergency department and even a 6 bed PICU/NICU. They take medical volunteers (medical students, third year pediatric residents, attending physicians) as well as non-medical volunteers.

KIDS International Development Society: http://kidsdevelopmentsociety.org/index.html

Angkor Hospital for Children: http://www.angkorhospital.org/

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