A lot of people wonder about what my work is like here, and it’s definitely hard to describe! So here is a run down of my day to day life at the hospital.
A typical day starts around 8 am in the outpatient department where I arrive to hundreds of patients crowded into a long hallway waiting to register for various clinics. There is a church service in the outpatient area every day and I usually arrive just in time to hear the last hymn resonating down the corridor. After being issued a number at registration, patients sits on long benches waiting to be seen by their physician. There are always soo many eager faces, and I can never tell how many of them are waiting to see me. Some days I see 10 patients, and some days its 40 – I really never know how the day will go! Our method for scheduling is a simple paper calendar where we make ticks marks to keep track of how many patients are told to come for a visit on each day….so not very precise!
Before clinic starts there are usually a few patients that have come early to talk to me. A single working mother who is struggling to keep up with the complicated skin care of her son with severe atopic dermatitis – I write a letter to social work to see if she can get some assistance (this has surprisingly worked a few times!!). An erythrodermic patient who was unable to get any of the medications we prescribed to him the previous week who has severely worsened – I arrange for him to be admitted so that we can administer IV medications because the hospital is out of oral and topical steroids that week. Maybe a patient or two from the day prior who need help with transport back to their villages because they cannot not afford the ride home after their appointment (about $3-$5). I try to arrange hospital transport for them or often just give them the money needed to get home.
Then, we start clinic! I am always working with a Derm resident from the US – these residents rotate every 4 weeks and come from all over the country (they are super awesome and make work so much more fun). I also work with local medical students and residents to teach them basic dermatology skills. We see a wide variety of conditions in a wide variety of patients. Some days its mostly simple things like eczema and acne. Then some days its back to back patients with bizarre/complex/severe/challenging skin disease. But even the common conditions that should be simple to treat, are a major challenge too because of the lack of availability of medications and the difficulty in properly counseling patients about their condition/how to manage it. A large portion of our patients are HIV positive (about 60% in the hospital setting). Their skin diseases present in unexpected ways and are often more refractory to therapies. Each patient brings a unique set of challenges – diagnostic, therapeutic, psychosocial, economic, compliance or communication related – you just never know what to expect. I can sometimes spend 45 minutes with a patient who has a simple skin tag because they cannot understand the concept of a benign skin growth. Communication is a major issue. I get help with translation to Setswana from a local nurse or from one of the local medical students or residents in clinic. Often there is a shortage of nurses and I have to work without a translator. Although a large proportion of people understand English, they have difficulty understanding medical terminology. I end up spending a lot of time searching for someone to help translate during clinic!
After finishing clinic, we may have a couple of inpatient consults to see. Again, these can be something as simple as shingles to a severe life threatening infection or drug eruption. The inpatient wards were initially confusing, disorganized and daunting – it has taken months for me to figure out how to navigate care for inpatients… with limited success.
The next step is to hand carry any cultures done to a central intake desk to get them assigned a specimen number, then we drop them off at separate locations for the bacterial, the TB or the fungal micro labs. Final stop is the pathology lab where we drop off any biopsy specimens. This is also where we spend quite a bit of time trying to plead with the staff to process our specimens as fast as they can. Our turn around time from the day of biopsy to the day we get the corresponding slide back is about 4- 6 weeks! Once we have the slide, I read it myself, then read it with a local general pathologist. If we cannot come up with a firm diagnosis, we will load the slide on a robotic telederm scope to be read by a dermatopathologist in the US. This adds another 4-6 weeks onto the time it takes until we get a diagnosis for our path specimens! A lengthy and frustrating process, especially when we are trying to get a rapid diagnosis for really sick patients.
If there is any time left in the day, we look up lab results and try to find someone to help us translate to call back patients with results. More often than not the labs that we ordered did not get done and we have to get patients to come back in to re-order them. Also many patients miss their follow-ups. We have mobile numbers to contact patients, but if they don’t have enough “minutes” loaded on their phone you just get an “out of service” recording. There is no voicemail here and texts also don’t go through if there aren’t minutes. So we are always working through a huge call back list of patients – some we have been trying to reach for months!
Then the work day is over and I get picked up by Garrett and Skippy! We only have one car so he just drives me the 10 minutes to/from the hospital. I come home and usually lay down for a while to think about the day. There is always a flood of emotions – ever-present hunger because we seldom eat lunch, frustration at all the inefficiencies, sadness at the needless deaths I often see, and anxious uncertainty wondering if I did the right thing for my patients. There is no manual to look at, no one else to look to for answers, I just do the best I can to help each patient even if it is only in some small way. There are days when the setbacks are so disheartening! But my solution has been to cultivate the joy that comes with small victories. My heart sings when a patient comes for follow up who has been able to get everything I prescribed, used it as exactly directed and has significantly improved as a result. This experience should be so commonplace as a physician but I never take it for granted now. At the end of each day, I try to pick out all the positive things that happened however small or few they may be. And very often there is something incredible and life changing that we are able to accomplish for a patient – and those are the moments I hold onto!
So why am I doing this? Why take a 90% pay cut to work in such a frustrating system? Why move across the world with my husband and dog?
Because these people really need a dermatologist! They need someone who will fight to get the medications they need, help them understand their skin conditions, help them navigate this frustrating healthcare system. After spending 24 years in school and investing a small fortune into becoming a physician, I want my skills to benefit people who really need it. With this one life, I want to try new things and push myself to learn and grow as much as I can. And I do learn SOOO much every day here – not just about dermatology or medicine. I learn so much about people, about life, about myself and about the world. It really is incredible. Although it has taken time to get used to….I appreciate the slower pace of life here, that the focus isn’t on how much you accomplish or how many hours you work, but on enjoying life. People actually get 6 weeks of vacation and no questions asked sick leave when they are sick. Crazy right? But who knows, maybe I will get burnt out. Maybe I will decide I hate complicated medical dermatology. Maybe I will want to go back to Colorado and only practice cosmetics. Maybe I will even give up dermatology and decide I want to do something else with my life! Or maybe I will never want to leave Botswana. Who knows what will happen tomorrow, but I feel good about what I am doing today!