St Francis’ Hospital is a large and busy hospital serving the local population of Katete District (over 200,000 people) and receiving referrals from all over the Eastern Province of Zambia (about 1.5 million people).
In Zambia, the concept of a GP or family physician only exists in the private sector. The public health system provides primary care through health centres, staffed by clinical officers, nurses and ancillary staff. These people have been trained to identify and manage common clinical presentations such as malaria, but they are not doctors. The patients who are referred to the hospital to see a doctor usually have had little or no treatment started. Therefore, although my work involves seeing patients in a secondary care setting, it has a feel of primary care to me.
For the past few months, the immense workload of the three medical wards and the daily general outpatient clinic has been shared out between two doctors from New Zealand and two local doctors. Now that I have arrived, and two more doctors from the UK are arriving this week, there will be 7 of us, which should make things more manageable.
My normal working day consists of an 8am ward round, followed by the outpatient department (OPD) clinic from late morning until 5pm, and finishing with an evening round of the most unwell patients and new admissions.
By the time I reach the Outpatient Department at 11am, the queues have already stretched outside the building, and I literally have to push and shove to get in the main door. Inside the building, there are people pressed shoulder-to-shoulder covering every inch of floor space. There is more jostling so I can get to the clinic room, grabbing a Chichewa translator on the way who will help me with the consultations. 93,038 people are seen and treated annually in OPD (on average, 255 per day). Today, I was the only doctor in OPD in the morning, and there were two of us in the afternoon. Nurses and trained clinical officers also see and manage patients, but that’s still a lot of patients to see!
If there is a queue system, I haven’t worked it out yet. However, nobody seems to fight or shout, and although there are way too many people in a confined space all heading for the same consulting room, it manages to seem almost orderly.
All the doctors and medical students share one consultation room for the general clinic, so there can be 3 consultations going on at once within a small room discussing private issues such as HIV status, examining patients behind an old screen in the corner of the room.
Some of the patients I see have problems that I know how to investigate and treat, but using options that are not available here… so I have to do some educated guessing and improvising along the way. Drugs frequently go out of stock making it even harder – for example, try investigating and treating dyspepsia and suspected H. pylori infection with no H.pylori test, no endoscopy, and Omeprazole, Metronidazole and Amoxicillin all out of stock! Some of the patients have problems that I do not know how to investigate or treat, this is difficult, especially when there is nobody to ask for advice and 253 patients yet to be seen!
However, the hardest thing is physically leaving OPD at the end of the day. At around 5pm, I need to return to the ward for my evening round. However, there are usually still a lot of patients waiting to be seen in the clinic, and as I walk out of the room they start approaching me with their notes in their hand saying ‘dokotalo, dokotalo’ [doctor, doctor]. I know that they have probably travelled a long way to be seen. Once I leave, if they are unwell enough, a clinical officer may see them. If they are stable, they will likely have to return to repeat the whole process tomorrow. I lower my eyes to the ground and mutter ‘pepani, pepani’ [sorry, sorry] as I walk away.