Survival of the Fittest

In everything I did, I showed you that by this kind of hard work we must help the weak, remembering the words the Lord Jesus himself said: 'It is more blessed to give than to receive.' (NIV)

- Acts 20:35

Whatever you do, work at it with all your heart, as working for the Lord, not for human masters.

- Colossians 3:23

Working in a South African Public Sector Hospital

One of our doctor friends likes to joke that “survival of the fittest” is the rule in SA’s public hospitals: only patients who are strong enough can survive care in the public sector.  (Roughly 90% of South Africans – over 40 million people – receive their medical care through the public sector.)  Many patients are already extremely sick with end stage AIDS and would die even with the best care, but far too many others suffer iatrogenic injury or neglect on a daily basis.  (‘Iatrogenic’ refers to illness or injury caused directly by medical treatment: medication errors, side effects of treatment, incorrect treatments, poorly done procedures, etc.)

Iatrogenic injury can result from poor training, poor judgment or carelessness.  We often get frustrated that so much of our time is spent treating or reversing iatrogenic problems.  Medical training here has minimal supervision, and doctors do not have to go through residency training to practice medicine (they only have to graduate medical school).  Interns (who are either 1 or 2 years out of medical school) can see patients on their own, prescribe treatment and send patients home — all without any direct supervision from a more senior doctor.  One of our colleagues, a trauma surgeon originally from Bulgaria, told us about an incident that occurred while he was working at another hospital (the three of us are the only residency trained physicians in our hospital of 220 beds, an emergency department, a labor ward, a nursery, and multiple outpatient clinics that see hundreds of patients each day).  One day he was seeing his patients on the wards, when a nurse asked him to see a patient who had had colon surgery the previous day.  He replied, “I’m the only surgeon at this hospital.  I didn’t operate yesterday.”  She answered, “One of the interns did.”  The intern had never seen the operation, or been trained to perform it.  Another intern who had seen the operation the previous week, had given his classmate verbal instructions for the procedure.  Not surprisingly, the patient died later that day.   

The cottage we stayed at with my family in Northern Drakensberg.

Outrageous as this story sounds, it is not uncommon.  Professional standards are not enforced, teaching is unstructured at best, self-directed learning is not emphasized, and human life is cheap.  We work with interns daily, and sadly many do not take their work seriously.  Doctors at all levels of training or seniority come late and leave early, miss work for frivolous reasons, and treat patients disrespectfully.  At our hospital interns rarely have formal lectures, and are often asked to see entire wards full of patients on their own when the senior doctor is sick or on vacation. When I asked one of the interns what consequences there were for interns who behaved unprofessionally or acted negligently, she told me that interns rarely fail rotations because training programs simply want to move bad doctors along as quickly as possible.  This is a major problem, because internship is the only formal training required for South African doctors after medical school.  It has recently been increased from 1 to 2 years, ostensibly to provide interns with more training, but the truth is that the public sector needs more interns to staff its hospitals.  Every day we see the results of unsupervised intern care: iatrogenic injury, prolonged hospitalization, and premature death. 

It is not surprising that a poor foundation in medical school or internship can lead to poor medical judgment, incorrect treatment, and bad outcomes for patients.  Nevertheless, poor training is not an excuse for poor care: doctors should be life-long learners who never stop honing their skills.  Many doctors here do not read textbooks or journals regularly (or at all), and continue giving incorrect or even harmful care.  We see sick, elderly patients on 10 to 15 medications, many with dangerous side effects.  Some patients have been on the same medications for years, with no blood testing and no dosage adjustments.  These medication errors can result in hospitalization, disability, or even death.

The view of the Ampitheatre from our cottage.

Last month a patient was brought to the ER unconscious, breathing heavily and slowly.  While I was examining her, she stopped breathing.  I immediately began CPR and called for help.  We put in a breathing tube and placed the patient on a ventilator (breathing machine), one of two in the hospital.  Within hours, the patient was found to be brain dead – likely the result of a major brain bleed.  When I reviewed the chart, I found that  one of the interns (actually a relatively good one) had seen the patient 3 days earlier.  Even though her blood test showed that her blood was already dangerously thin, the doctor kept her on the same dose of blood-thinning medication instead of reducing it.  The intern had been seeing patients completely unsupervised.  She thought she knew how to use a dangerous medication, but she made a mistake.  Likely as a result, the patient died.  I took the intern aside to explain what had happened, so that she could learn. However, she is not solely responsible.  The entire medical system is at fault.

Even when doctors order appropriate treatment, care often is not delivered.  During night shift, only half the nurses work at a time; the other half go to sleep, and wake to relieve their fellows halfway through the shift.  The half that are on duty, are often unable to deal with the volume of patients in the unit, so they leave important tasks – medications, blood draws, monitoring of vital signs – to the nurses coming on duty after them. (And sometimes nurses simply refuse to work: they sit, they chat, they read magazines – anything but patient care.)  One night I admitted a very ill HIV patient from the emergency department to our ‘high-care’ unit.  I ordered for the patient’s blood sugar to be checked every 4 hours since she could not eat.  When I went to check on her a few days later, her sugar had not been checked since admission.  (‘High-care’ is supposed to provide critically ill patients a higher level of care: 2 nurses and a senior doctor for 4 patients, compared to the general wards where 2 nurses and a junior doctor care for 20-25 patients.)



Baboons are considered a dangerous nuisance here. 

The greatest disappointment is how healthcare workers treat patients—often with complete disrespect and disdain.  Patients are herded through the hospital like livestock, with little attention or kindness from the medical staff.  The most common excuse is that doctors and nurses in the public sector are overworked, followed closely by ‘public sector patients are more difficult.’  (Most patients do not know their medications; when asked why they came to the clinic, most say that it is their appointment date – few can give a symptom or time course for their illness.  In Zulu culture, patients go to sangomas, or spirit healers, who tell them directly about their ailments; when these patients present to a Western doctor, they expect him or her to know what the problem is without saying anything.  A colleague likens it to practicing veterinary medicine.)  Both excuses contain kernels of truth.  It is frustrating to work here—conditions are poor, patients are uneducated or have poor cognitive skills, and resources are lacking.  However, there is no excuse for the poor treatment that patients receive here.  Dogs in the US get far better treatment than human beings here.  One of the doctors acted concerned for me because a nurse told her that I was working too hard and giving each patient individual attention.  I was confused by her comment: how do I treat a patient without giving him individual care?   I tried to explain that patients come to the emergency room very sick and they deserve personal care and time, even if it is busy and I am tired.

Picture taken while horseback riding just before sunset.

At this point, in the midst of all this negativity, I feel obligated to say that we have met doctors, both South African and foreign, who are truly dedicated, well-trained, thoughtful, compassionate, humble professionals.  These doctors see the suffering around them, and it spurs them to work more diligently, learn more, and deliver compassionate, quality care.  In addition to clinical care, many are involved in teaching, policy-making, and research.  Unfortunately, these doctors are few and over-stretched.  They carry a heavy burden, and burn-out is not uncommon.

Initially many doctors and nurses probably thought we were dumb or poorly trained because we are far worse at placing IVs than everyone else – also we do not do anesthesia or perform c-sections independently.  However, we have slowly gained their respect.  They realize we are hard-working, fast-learning and conscientious about delivering good medical care.  We have learned some of their procedures and medications (long discontinued in the US).  However, we are also sharing our training, knowledge, and way of practicing with those around us; it is gratifying to find that now, our senior colleagues sometimes seek our advice on complex patients. 


A picture taken during a hike.

I find this quote from a 19th Century Boston minister, Edward Everett Hale encouraging: "I am only one; but still I am one. I cannot do everything, but still I can do something; I will not refuse to do the something I can do."  For us, we realize that we are only two individuals working in a very flawed system and country and we cannot fix all the problems, but we can give our time, medical expertise and compassion to do what we can to help the poor.

A full rainbow arching over a few Drakensberg homes.

South African Fact:

South Africans commonly say “shame,” an exclamation that denotes sympathy, as in "shame, you poor thing, you must be tired; you worked all night."