This past spring, I went to Dar es Salaam, Tanzania to do an internal medicine elective at Muhimbili University of Health and Allied Sciences. I rotated through two sub-divisions of internal medicine while I was there: infectious disease and cardiology.
When I initially stepped onto the infectious disease ward, I saw the janitors mopping the cement floors with soap and water. The ward was crowded and the patients lying on the floor had their mattresses mobilized to the stairwell so their space could be cleaned. I noticed not all of the patients had mosquito nets and only about a quarter of the fans were on despite the hot and humid environment. The sun was bright and shining so the lights on the ward were unnecessary. I noticed two people that were examining patients and writing notes — the interns.
I walked up to them and introduced myself and we examined patients together. The first patient we saw was a young male with human immunodeficiency virus (HIV) who presented to the hospital with dyspnea. Examination of the patient revealed a normal blood pressure and heart rate with distant heart sounds. The lung sounds were normal. EKG showed normal sinus rhythm with normal voltage. The chest x-ray showed cardiomegaly. An ultrasound of the heart confirmed pericardial fluid around the heart, but no evidence of tamponade. The presumptive diagnosis made by the team was tuberculous pericarditis based on the clinical picture. There were no additional laboratory tests ordered to definitively diagnose the etiology of the pericarditis like acid fast bacilli smear or culture of the sputum. The patient was treated empirically with anti-tuberculous medications and steroids with improvement of his symptoms.
The most important lesson I learned with regard to medicine is that a lot can be learned about a patient based on physical diagnosis alone. As technology is refined to obtain the most picturesque images of the body and the lab tests are becoming accurate to the decimal point, the skills of the physician are being lost. During my four week elective, I was able to put my skills to the test and learn from my interns how to rely on my physical diagnosis without having advanced laboratory tests and imaging studies at my fingertips.
I worked closely with the interns as I do not speak the native language of Swahili and could not communicate with the patients directly. However, the medical records were written in English and I was able to read through patient’s charts. Interestingly, there was a cardiologist from China who was a rotating attending physician for six months at the hospital in Tanzania.
This illustrates one of the most fascinating aspects about medicine: it is a universal language that we were all able to understand despite being from different parts of the world. As we all reviewed a patient’s computed tomography (CT) scan with contrast we were all able to see an aortic dissection that started from the aortic arch and extended down to the iliac arteries. The patient knew how to communicate with us by clenching her chest to let us know she was having chest pain. The patient’s blood pressure was being well controlled on medications she was taking by mouth and she was waiting to be transferred to India to get a repair. Despite the language barrier, we were able to diagnose her and ensure she would get appropriate treatment.
While working in an outpatient HIV clinic, it was interesting to note the interaction between the physician and the patient. In Tanzania, the government will pay for all HIV medication and anti-tuberculosis medications for the patient if they do not have any insurance. In one case, a female patient had oropharyngeal candidiasis that required treatment with oral fluconazole.
However, given she had insurance the government would not pay for her medication. Since it was too expensive for her, the physician prescribed the medication to another patient who had coverage under the government so it could be given to the patient who could not afford it.
In all, during my four week elective abroad I was able to learn a lot about how medicine is practiced in a resource limited setting. Additionally, I got to be immersed in another culture and experience the dynamic between a physician and a patient in an environment different from what I had been exposed to previously.
Heather Lee is an internal medicine resident.