The awkward moment when you have to tell a senior doctor he has put his stethoscope in the wrong way round

20.9.11:

Today we started in OPD with one of the clinical officers. I know I over use the words “frustrating or frustrated” in my elective blogs, but yet again that’s how this morning left me feeling. The clinical officer we sat in with is not what I would describe as one of the better ones so lots of patients we saw whilst sitting in with him received treatment that was not ideal even for here; however the case that really frustrated me above all the others was that of an 11 year old girl who was presenting with a 1 week history of cough and abdominal pain.

Whilst she might only be attending OPD with a one week history of illness that doesn’t mean you should ignore blatantly obvious signs that the child had been also suffering from some form of severe chronic illness. The girl was mostly carried in by her mother and her legs were absolutely stick thin (and I’m not talking just naturally skinny thin) with obvious muscle wasting. She was completely malnourished. The clinical officer recognized this but only when we pointed her legs out to him – otherwise he was just going to address the problem of her acute symptoms in spite of such obvious malnutrition. Even when we suggested to him that perhaps she was suffering from chronic immune suppression and had been ill for some time he kept just saying she had only been ill for a week.

Eventually though he did ask the questions we were telling him he should (such as has anyone else in the family been ill and have her parents ever been tested for HIV). Turns out her father had died "of a cough" shortly after the girl was born (probably TB or pneumonia secondary to AIDs - both are relatively common opportunistic infections that immune compromised patients suffer and die from). So we said he should test the girl for HIV and he replied he couldn't because she was a child. When AJ and I both simultaneously exclaimed why not he didn't really have a reason for us, and we have since seen other children being tested so not sure what he was on about here! Eventually he agreed that maybe the mother should be tested and finally asked her if she had ever been tested before. Turns out she had been diagnosed as HIV positive a few months back! Why had it taken one of her children to become ill for HIV testing of her children to be considered??! It really is truly baffling.

At least the girl in the end got taken for a chest x ray for ?tb and has been admitted to the paediatric ward. I hope she does get tested for HIV and if it she is positive (sadly I really think she will be) gets the antiretrovirals that she could have done with starting years ago.

The rest of the morning we spent with one of the senior doctors on the female ward round and then went with him to review some patients on other wards which needed a senior review. He asked us to thoroughly examine the cardiovascular and respiratory systems of one patient while he did most of the ward round quickly. When he came back he asked to borrow my stethoscope to listen and confirm our findings, I watched him put in the stethoscope carefully because last time he borrowed my stethoscope I thought he had put it in wrong but hadn't had a chance to look closer before he took it out. Sure enough he put it in the wrong way round again and we had to tell him because with it the wrong way round it would be virtually useless and he would only pick up the most obvious signs (trust me I have just experimented with mine to check I wasn't being unfair in saying this!). Blimey, putting a stethoscope in the wrong way round is to put it bluntly such a rookie mistake - it’s something I remember doing as a 16 year old during medical work experience, not something you expect a senior doctor to be doing regardless of country! I would assume it was just a one of absent minded mistake if I hadn't seen him doing it before. I wonder if he is the only member of staff who does this - going to be keeping my eyes open for this now!

The senior doctor was not alone in his mistake.. Izzy from Greys anatomy often put her stethoscope in the wrong way round too, that said the actress was not really medically qualified or responsible for peoples lives...

A more modern clinic
In the afternoon we went with a different senior doctor (Dr M) to his private clinic in a larger village nearby. Wow, so different from the hospital! Whilst it was not finished yet as he only started the clinic a year ago, the bits that were finished were so much nicer, more spacious and private than rooms at the hospital. The equipment looked more like stuff you see in the NHS - for example the examination bed was one that could be adjusted into the different sitting angles that are required to examine patients more easily. He was clearly very proud of his clinic and gave us a grand tour and told us all the things he wanted to do to it. Eventually he hopes to turn it into a small hospital, I hope he succeeds because I think he would create a pretty good hospital. Most importantly though, Dr M was amazing with the patients and really seemed to have good medical knowledge like you would expect from an experienced doctor. He was also a really good teacher to us and let us takes histories with him as the interpreter and got us to examine the patients under his guidance. All in all a good afternoon and to be honest it was good to see that the hospital we are based in may not be a reflection of Tanzanian health care as a whole.

Found out from Dr M on the way back that he is the only doctor at the hospital who has studied medicine at university, the others were all clinical officers who did some kind of conversion course to become doctors. .... This explains quite a lot! I would say that judging on the kind of clinical ability we have observed that perhaps such conversion courses should not be possible but apparently when Tanzania gained its independence there were only 12 doctors in the whole country (of which I gather Dr M was one) so they didn't have much choice but to find a way to create more doctors quickly. A bad healthcare situation really and I guess doctors who have the ability to treat at least some conditions are better than none at all so maybe I should try and be less critical of the healthcare standards here... I will try, but I'm not going to sit back and do nothing if patients are at risk if I think I could do something/say something that would help.

Halfadoc x