There has been something of a stalemate at one of the hospitals I work in, they have told me I should be more Cambodian in my character when doing follow up & coaching. From observation & their feedback I think this would involve me;
1) Never disagreeing with any of the doctors - ever
2) Disregarding national guidelines & protocols ratified by the MoH & supported by evidence based medicine
3) Keeping my knowledge, expertise & ideas for solutions to myself as they are worthless & insignificant
4) Score the hospital very highly despite not actually witnessing correct practice.
The head nurse commented to me one morning that the hospital was in trouble, again, after reports of corruption. The NGO I work for was some how implemented in making the complaint. What do you think of this? I queried - testing the waters. Oh - it's entirely fair because the hospital still does have many under the table payments - was his not so unsurprising response. So maybe, I mused, I should tell the doctors that if they pay me $20 I'll write them a really good follow up report?
He wordlessly slapped on the shoulder & he left the room laughing. For those of you that can't read non-verbal Khmer - that's a yes!
So this week with a devil may care attitude I found myself & my assistant walking with a spring in my step to the previously off limits paediatric ward to do coaching & follow up for TB screening. This is an easy thing to do - clinicians simply have to think about TB when seeing a child. By raising awareness they may then think to ask about TB contact, any symptoms suggestive of TB, look for signs of TB & refer if they have suspicions. It seems a simple thing but when the doctors here normally don't take a history or examine patients it becomes slightly more challenging.
It's not like neurosurgery or interventional cardiology where there has to be many expensive resources & extensive training is required, it simply involves a health worker using their brain to ask the right questions.
Last week I cancelled a planned TB follow up because the only doctor on duty was busy with a sick child & OPD was completely empty, later the angry head of department told me that I should just talk to the doctor in his office & go through the follow up form without having to see any patients. He couldn't understand the worth or point of seeing people in their clinical roles. "My staff know it all" - I was told. But we all know that there is a significant gap between knowing & doing - I write this as an obese, unfit, middle aged, ex-smoking Doctor who has recently rediscovered the joys of wine. No one here seems to be able to appreciate that a question & answers session, be it verbal or written, is not the same as on the job coaching & supervision. If checking retention of knowledge was all that was needed & sufficient to initiate behaviour change then post-tests would be the gold standard in vocational training & the medical training programmes in developed world are all completely defunct.
This time, the ward were not expecting us, despite many phone calls to the angry boss man but none the less they shrugged & let us stay anyway. The lovely Chief of ward - who deliberately sent me into the lion's den a month ago where I got my ear chewed off for asking to discuss SAM with angry boss man - smiled warmly at me & even laughed when I told her I would never listen to her advice again. I was set up.
The MA on duty is generally extremely grumpy & rude. She snapped at my assistant "What do you want?" & when L explained she shouted, "well there is no point sitting out there you won't hear anything!"
We went into the OPD room where she saw a child with a history of sore throat & fever for one day. She asked about TB contact & any general symptoms of TB. She went in search of a tongue depressor & even downloaded a torch onto her iPhone in order to look at the child's throat. In short she did a perfect TB screening of the child. L & I stood in the corner stunned. I have never seen the staff do anything completely by the book and to near perfection, she even washed her hands 3 times. Although for a long time I have harboured suspicions that they were capable of doing the right thing, I had almost lost hope that I would ever live to see it.
Then the chief of ward came in with 2 stools for use to sit - we must have looked like we were about to pass out.
The second child also had a perfect screening & this time there was cause to investigate further for TB due to the child's symptoms, so she explained all this patiently to the grandmother (the parents, like so many, are away working illegally in Thailand) who was then given time to ask questions. When there was no confirmed history of TB contact the MA even asked about adults in the neighbourhood with chronic cough. She checked the child's weight & even though the ward has no growth charts she could comment on the fact that the child had failure to thrive.
I leant back against the wall for support - in an unfamiliar state of happy shock.
After the child had gone with her Grandmother for a chest X-ray I told the MA that I wish I could have filmed her as she had just done two perfect consultations demonstrating how to screen for TB in children. Omitting the part when the child with a sore throat started to cry & the MA told her "If you don't stop crying I will admit you to hospital & give you lots of painful, horrible injections"! Other than that one small 'cultural difference' it was a gold standard consultation.
She looked less grumpy & hostile than normal, which I read as her to be positively beaming.
As we walked back to the office L said - What happened? I have never seen you behave like this with the staff?
I am not naive enough to believe what happened represents any major change in their practice or a personal achievement for me. In fact I assume that the staff had been told to do the business & deliver what ever we were following up on. I have no doubt that the moment we left the MA went back to monosyllabic history taking & minimal touching of patients, not giving TB a second thought. But for the time we had observed her she had shown me that she could, if she wanted or instructed to, screen children for TB perfectly well. So they do know it & my job is meant to be to help & encourage them to actually do it.
L however seemed to imply that perhaps it was actually me who has had a change in character. Maybe its just temporary change in me as a result of Pchum Ben induced sleep deprivation, maybe I had subconsciously taken the previous weeks advice from my male Cambodian work colleague or as my best Cambodian friend texted me on an completely unrelated matter - But sometime a place can also change people? Can't it? ;-)
1) Never disagreeing with any of the doctors - ever
2) Disregarding national guidelines & protocols ratified by the MoH & supported by evidence based medicine
3) Keeping my knowledge, expertise & ideas for solutions to myself as they are worthless & insignificant
4) Score the hospital very highly despite not actually witnessing correct practice.
The head nurse commented to me one morning that the hospital was in trouble, again, after reports of corruption. The NGO I work for was some how implemented in making the complaint. What do you think of this? I queried - testing the waters. Oh - it's entirely fair because the hospital still does have many under the table payments - was his not so unsurprising response. So maybe, I mused, I should tell the doctors that if they pay me $20 I'll write them a really good follow up report?
He wordlessly slapped on the shoulder & he left the room laughing. For those of you that can't read non-verbal Khmer - that's a yes!
So this week with a devil may care attitude I found myself & my assistant walking with a spring in my step to the previously off limits paediatric ward to do coaching & follow up for TB screening. This is an easy thing to do - clinicians simply have to think about TB when seeing a child. By raising awareness they may then think to ask about TB contact, any symptoms suggestive of TB, look for signs of TB & refer if they have suspicions. It seems a simple thing but when the doctors here normally don't take a history or examine patients it becomes slightly more challenging.
It's not like neurosurgery or interventional cardiology where there has to be many expensive resources & extensive training is required, it simply involves a health worker using their brain to ask the right questions.
Last week I cancelled a planned TB follow up because the only doctor on duty was busy with a sick child & OPD was completely empty, later the angry head of department told me that I should just talk to the doctor in his office & go through the follow up form without having to see any patients. He couldn't understand the worth or point of seeing people in their clinical roles. "My staff know it all" - I was told. But we all know that there is a significant gap between knowing & doing - I write this as an obese, unfit, middle aged, ex-smoking Doctor who has recently rediscovered the joys of wine. No one here seems to be able to appreciate that a question & answers session, be it verbal or written, is not the same as on the job coaching & supervision. If checking retention of knowledge was all that was needed & sufficient to initiate behaviour change then post-tests would be the gold standard in vocational training & the medical training programmes in developed world are all completely defunct.
This time, the ward were not expecting us, despite many phone calls to the angry boss man but none the less they shrugged & let us stay anyway. The lovely Chief of ward - who deliberately sent me into the lion's den a month ago where I got my ear chewed off for asking to discuss SAM with angry boss man - smiled warmly at me & even laughed when I told her I would never listen to her advice again. I was set up.
The MA on duty is generally extremely grumpy & rude. She snapped at my assistant "What do you want?" & when L explained she shouted, "well there is no point sitting out there you won't hear anything!"
We went into the OPD room where she saw a child with a history of sore throat & fever for one day. She asked about TB contact & any general symptoms of TB. She went in search of a tongue depressor & even downloaded a torch onto her iPhone in order to look at the child's throat. In short she did a perfect TB screening of the child. L & I stood in the corner stunned. I have never seen the staff do anything completely by the book and to near perfection, she even washed her hands 3 times. Although for a long time I have harboured suspicions that they were capable of doing the right thing, I had almost lost hope that I would ever live to see it.
Then the chief of ward came in with 2 stools for use to sit - we must have looked like we were about to pass out.
The second child also had a perfect screening & this time there was cause to investigate further for TB due to the child's symptoms, so she explained all this patiently to the grandmother (the parents, like so many, are away working illegally in Thailand) who was then given time to ask questions. When there was no confirmed history of TB contact the MA even asked about adults in the neighbourhood with chronic cough. She checked the child's weight & even though the ward has no growth charts she could comment on the fact that the child had failure to thrive.
I leant back against the wall for support - in an unfamiliar state of happy shock.
After the child had gone with her Grandmother for a chest X-ray I told the MA that I wish I could have filmed her as she had just done two perfect consultations demonstrating how to screen for TB in children. Omitting the part when the child with a sore throat started to cry & the MA told her "If you don't stop crying I will admit you to hospital & give you lots of painful, horrible injections"! Other than that one small 'cultural difference' it was a gold standard consultation.
She looked less grumpy & hostile than normal, which I read as her to be positively beaming.
As we walked back to the office L said - What happened? I have never seen you behave like this with the staff?
I am not naive enough to believe what happened represents any major change in their practice or a personal achievement for me. In fact I assume that the staff had been told to do the business & deliver what ever we were following up on. I have no doubt that the moment we left the MA went back to monosyllabic history taking & minimal touching of patients, not giving TB a second thought. But for the time we had observed her she had shown me that she could, if she wanted or instructed to, screen children for TB perfectly well. So they do know it & my job is meant to be to help & encourage them to actually do it.
L however seemed to imply that perhaps it was actually me who has had a change in character. Maybe its just temporary change in me as a result of Pchum Ben induced sleep deprivation, maybe I had subconsciously taken the previous weeks advice from my male Cambodian work colleague or as my best Cambodian friend texted me on an completely unrelated matter - But sometime a place can also change people? Can't it? ;-)
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