Quality Improvement

So here is a bit of an explanation about the project I'm trying to work on during this visit.

I won't spend much time here reiterating all of the difficulties one faces when working in Mulago hospital, as I've spent some time on this in previous posts (especially Incentives).  Suffice it to say that the problems of the hospital are almost never attributable to a particular individual, or the presence or lack of their innate intelligence, motivation, commitment or humanity (though undoubtedly there can be large interpersonal variation in these attributes, much as there are at Yale New Haven Hospital, and any large institution). Rather, the problems of the hospital are largely systems problems - aging physical infrastructure, understaffing, lack of resources, and, as I discussed before, the unspoken incentive structures that do little to reward good or to punish poor provision of patient care. And yet, while the current state of the hospital and its systems issues is inextricably linked to the historical (and ongoing) limitation of monetary, human, and technological resources, not every system improvement requires an increase in these resources.

As an example - as it currently stands in the hospital, communication between nurses and physicians is haphazard, at best. Resource limitation played a significant part in shaping the current system - there is a severe nursing shortage, making it all but impossible for nurses to join physicians on rounds. Longstanding cultural and societal norms also play a significant role, which tend to make interactions between (supposedly) higher and lower cadres rather more paternalistic. And yet, good interpersonal communication does not rely upon monetary resources.

Here is another, more tragic, example. I spent some time during this trip on the pediatric Renal/GI ward. The challenges of pediatrics at Mulago are very similar to those of medicine - especially on a ward where half of the patients have end-stage renal disease, without access to dialysis (which is pay-per-session), or transplant (for which they would need to travel to South Africa or India, and pay out of pocket). Those are problems that are very directly related to monetary resources, and therefore aren't ones that I have any power to fix.

But during my time there I was confronted with another type of problem.  A young child, perhaps 10 or 12 months old presented to the hospital after 2 weeks of watery diarrhea.  Diarrhea is a common illness amongst children all over the developing world, and is still a significant source of infant mortality (when it leads to severe dehydration). I met this child as I rounded with a Ugandan Senior House Officer (a pediatric resident). Oddly, the child did not look as severely dehydrated as some diarrheal patients - the mouth was not dry and pasty, and the child still had moist eyes and tears.  What was odd was that the child, though alert, was quite limp, and appeared to be in respiratory distress despite having relatively clear lungs on auscultation. As I reviewed the chart with the SHO, we found that a set of blood electrolytes had been measured in the Emergency Department (the day prior), and that the patient had a Potassium of about 1.3 (mEq/L). The normal range is from 3.5-5, which means that this patient had very severe Hypokalemia.

Most likely the patient had had ongoing potassium loss in the watery diarrhea, and had had only potassium-poor oral intake (like water or diluted porridge), thereby slowly depleting his body of potassium. Hypokalemia of this degree is life threatening, and because potassium shifts play a key role in nerve and muscle depolarization and firing, this degree of derangement confers a high risk for cardiac arrhythmias, and was also the likely cause of the patient's flaccid paralysis and respiratory distress (from respiratory muscle weakness).

The treatment, clearly, was potassium supplementation.  This degree of hypokalemia necessitates IV repletion, both for speed of treatment, and because GI absorption can be erratic in the setting of diarrhea. Undoubtedly, in the US, a child as sick as this one would be taken care of in the ICU, and their potassium would likely have been checked hourly as it was gradually repleted. Here, on the other hand, there are few high-dependency beds available, and if you send a test for serum potassium, you will not receive it back until the next day - but only if you get it there before the lab closes at 5pm. After that you may have to wait for the following day.

Our only choice was to replete potassium on the ward.  The problem is that overly rapid infusion of potassium is also life threatening (as it may also cause cardiac arrest). I sat with the resident, and we calculated exactly how many milliliters of the available concentrated potassium chloride solution to dilute in how many milliliters of normal saline.  We decided to infuse in aliquots of 100ml of the mixture, which we would give 3 times by the next morning.  Both the SHO and I spoke directly with the nurses on the ward, and we saw the initial solution mixed and hung above the patient.

I had other responsibilities in the hospital that afternoon, and was off of the ward. When I returned the next morning, I learned that the child had died at around 1am.  The SHO recounted that she had popped back by the ward in the late afternoon and found that only perhaps 10 milliliters of the first 100ml aliquot had actually been infused into the patient. Remember, that there are no infusion pumps - no machines to ensure steady flow of IV fluids at a pre-determined rate.  Rather, you just adjust a little plastic gadget that squeezes the IV tubing, thus restricting flow and then you eyeball how fast the fluid is dripping. The SHO spoke once again with the nursing staff about the planned infusions, and ultimately had to go home for the evening.

It's difficult to know what happened, but my guess is that the patient was simply never infused with sufficient potassium, and ultimately succumbed to respiratory failure. Alternatively, if someone had sped the infusion too much, the patient could have had cardiac arrest.  More likely, however, as had happened during the day, a nurse had hung and/or adjusted the IV drip rate, and overestimated the rate at which the patient would receive the fluids, thereafter moving on to her many other tasks, and never finding a moment to check back.

In the morning, I watched the SHO speak with the nurses.  She was appropriately upset. This was, she told me, the second child she had lost to hypokalemia recently.  Still, there were no raised voices, and it did not seem that she was inappropriate with the nursing staff (who, of course, were not the ones who had been on the ward overnight). Certainly, though, she voiced her frustration.

Some minutes later, I heard the nurses talking amongst themselves. It sounded as if they felt maligned. In Europe, one nurse noted to another, the nurses have no more than 5 or so patients each, and if they have critically ill patients, perhaps only 2. On that particular pediatric ward, which had about 30 patients, there were 2 or 3 nurses during the day and probably 1 at night. What could they have done, when there were no doubt other critically ill patients on the ward who also demanded their attention?

Well, I'm not sure exactly what they could have done. Certainly, they are in no position to hire more nursing staff, or to buy more infusion pumps.  But they could have done something differently. It's true that resource limitation has allowed these systems to grow into the dysfunctional tangle in which they now exist, but it is not true that there was no way to save that child. It is not true that the medicines and the expertise to infuse them were not present. It cannot be true that the overnight nurse did not have even the 5 seconds it would have taken to check on the infusion's progress, or the 2 minutes to hang the next one. What is true, is that there is no formal system in place to ensure that the importance of those tasks was passed on at shift change, and no system to make sure that those tasks were performed in a timely manner.

Rather than lament, or become resigned to the problems of the system, though, I would rather that the nurses realize that it is within their power to change the system in which they work in small but meaningful ways, that do not require additional resources, and may have saved that child's life.

That is what Quality Improvement (QI) work is about. Unlike traditional medical research, which mostly concerns itself with the discovery of new knowledge, QI projects aim to improve the performance of systems towards pre-defined goals. Although QI got its start in commercial industries (such as manufacturing), its techniques have been co-opted for use other areas. In medicine, QI projects strive to ensure that health systems provide care that is safe, effective, efficient, patient-centered, timely, and equitable (in line with the Institute of Medicine Guidelines).

Those goals sounds pretty grandiose from way out here in Kampala, but the message is simple and applicable - we need to improve systems to ensure that they provide proven care, and provide it well.

What might that mean on the Mulago National Referral Hospital Pediatric Renal/GI ward? Well, paper and pens are easily available. Each day after rounds, could the physician team write a bulleted list of only the most critical nursing tasks, to ensure that they receive special attention? Could a similar list be used to pass on critical tasks during nursing shift-change? What can we do to encourage staff to consistently complete these tasks? How can we reward good performance and remediate poor performance?

If you have an eye for systems issues, it doesn't take long to identify opportunities for improvement in a difficult work environment; there are many low-hanging fruit. The question is, how do you improve systems in a sustainable and resource-reasonable manner? And how do you incentivize people to spend their time and energy doing it? That is what my project here is about.

As I said - there are many low-hanging fruit, and by a few weeks into my first visit here I had plenty of ideas to work on.  But (long story short) I learned what many people working in development have learned before me - sometimes my ideas won't work because they are my ideas.  I don't live here. I don't work here. I don't spend most of my waking hours in Mulago Hospital. I don't know the system well enough to recognize what may be clear to others. I can't get done by email what needs to be done in person, and I can't get someone to do my work for me. (If only I could...)

Ultimately, I realized that instead of putting together a project myself, I needed to figure out a way to incentivize staff here to do QI work.  And so my current project was born.  I have been lucky enough to receive some monetary support from the Office of Global Health at Yale, and we will be using that money to provide a grant to a Ugandan Senior House Officer to perform a QI project on the medicine wards. After a competitive grant application process, the winning SHO will receive a grant which is intended both to reimburse their time spent on the project, and also to pay for project costs (such as data collection and materials).

As you might imagine, changing systems can be difficult, and as such, Quality Improvement work is a bit more complicated and rigorous than just trying to convince someone to pick up a pen and paper twice a day before sign out.  This is largely because, even if you do convince someone to do a task for a while, as soon as you stop bugging them, they'll probably stop doing it.  Even a simple task, such as getting a staff member to consistently use of a new form, requires a variety of changes to the context in which that staff member works. It's ultimately the changes to the work environment - the system - that will ensure that form use continues after you're no longer watching.

I'm far from a Quality Improvement expert, and I am learning as I go.  But I'm optimistic about our project here. I have been greeted with interest by the SHOs, who recognize, more than anyone, the difficulties of the system in which they work. So in addition to time on the wards, I've been spending time recruiting applicants, doing some teaching on basic QI concepts, and working to ensure approval and buy-in from the Mulago administration. So far, so good.

Application Deadline: December 21st.

Ebola, no Marburg, no Ebola

If you're into viral hemorraghic fevers, Uganda is kind of the place to be. As I write this, Uganda is at the tail end of it's third outbreak in the last 6 months.

There are a number of viral diseases that can cause hemorrhage, but the ones that keep popping up in Uganda are Ebola, and Marburg virus diseases.  Ebola and Marburg are related viruses, both of the same family (Filoviridae). They cause short-lived, intense illnesses, characterized by acute onset of high fever, chills, malaise, general prostration and high mortality. The symptoms largely reflect the storm of pro-inflammatory mediators released by the infected cells of the innate immune system (mostly macrophages) which spiral out of control, and can lead to the hemorrhagic manifestations which make the diseases both so scary, and so apt for use in hollywood films - basically, bleeding from every orifice.

The case fatality rates range from 21% -- if you contracted Marburg virus in Germany in a 1967 outbreak -- to 90% -- if you contracted Marburg virus in Angola in 2005. The case-fatality ranges for most of the relevant Ebola strains are similar - from 50-90% (with all outbreaks occurring within Africa). There is debate as to whether the wide mortality range documented for Marburg is attributable to strain characteristics, or the quality of available medical care at the outbreak sites - I suspect that it was at least in large part due to the latter.

While Ebola Virus takes its name from a river in what is now the Democratic Republic of the Congo (then Zaire), interestingly, Marburg Virus actually takes its name from Marburg, Germany. Marburg was the city where hemorrhagic fever made its Western debut when in 1967 an outbreak infected 25 individuals harvesting tissue to produce the poliovirus vaccine.  They were harvesting tissue from -- you guessed it -- monkeys sent from Uganda. And while Germany has been lucky enough to avoid further outbreaks (probably because the Ugandan monkey tissue industry isn't what it used to be), central and East Africa have not been as lucky.

Most often, outbreaks occur when an index case comes in contact with an infected monkey. Monkeys are not thought to be the natural reservoir of the viruses, as they also become ill and often die from the disease. When encountered, though, weakened or dead monkeys often end up as food. In an outbreak in Gabon in 1996, a dead chimpanzee was butchered and eaten by 19 people, all of whom quickly became ill. There is also some evidence that fruit bats may be a reservoir for Marburg virus, as several European tourists developed the disease after separately visiting a particular (bat-ridden) cave in eastern Uganda (one of whom died).  Most often, however, the index case does not live to tell the story of their exposure.

Generally, the disease spreads by direct contact with the bodily fluid of actively ill patients, or by iatrogenia. In one terrible outbreak in 1976, the index case presented to a small missionary health outpost in (then) Zaire. Because he presented with high fevers, he was treated with injectable quinine for severe malaria.  The needle was then washed in a pan of water with the other needles with which they routinely injected all febrile patients with anti-malarials. Almost 100 patients were infected and died. It is also possible that the 2006 Marburg outbreak in Angola was caused by inappropriately reused blood bank equipment.

Generally, however, infection only occurs with direct contact with bodily fluids, either during illness, or during the common (sometimes religious) custom of washing the body of the deceased before burial. There is no evidence of infection being acquired from asymptomatic patients during the incubation period. There has also never been clear evidence of airborne transmission in previous outbreaks (despite what Dustin Hoffman says). There was, however, one episode in 1996 in which a patient presented to a hospital in Zaire with abdominal pain, and underwent exploratory laparotomy. There wasn't much to find in the abdomen, but they did manage to aerosolize some blood, thereby infecting the entire OR staff and subsequently their families and caretakers when they became ill. There was also a recent article purportedly documenting airborne transmission in laboratory conditions between pigs (another potential reservoir) and monkeys.

Perhaps the most unexpected tidbit I found about transmissibility was that, in fact, Ebola and Marburg are also potentially sexually transmitted diseases.  There has been well documented viral persistence in (amongst other places) the semen of surviving men for up to 3 months after infection, and following the 1967 outbreak in Marburg, there was one documented sexual transmission from a survivor.  Oops!  So I guess the lesson is this: pity sex with a cancer patient - OK; pity sex with a hemorrhagic fever survivor - best wait on that.

So what's happening here in Uganda?

The first outbreak this year was an Ebola outbreak, occurring in Kabaale (a southwestern area of Uganda). It was announced on July 29th, and the last confirmed case was discharged from the hospital on August 24th, though the outbreak was not officially declared over until October 4th (observing a pre-determined observation period that is about twice the maximum incubation period). There were 24 confirmed and suspected cases (only a portion of which had confirmatory viral testing performed), including 16 deaths. The majority of deaths, as in most outbreaks, were amongst the family of the index case.

Shortly thereafter, Uganda also suffered an outbreak of Marburg Virus this year.  The outbreak began in October, and was declared over in late November (days before the most recent outbreak), and ultimately included 20 probable or confirmed cases, and 9 deaths which were spread across 4 districts (Kabaale, Ibanda, Mbarara, and Kampala). The index case was a school teacher, and it is unclear what his exposure might have been.  Both he and later his infected caretakers travelled by bus around central and southwestern Uganda, including through the busy capital here, mostly to assist in the care of sick family members (who initially, at least, were sick with something other than Marburg).

The most recent, and not yet officially concluded outbreak of Ebola began in Luweero, a small city about 40 miles north Kampala. The index case was a Boda Boda driver, with an unknown exposure, who died on October 25th, having been taken care of in the village by his family and never having visited a health center. The next two deaths occurred on November 10 and 12th, were both family members and caretakers of the index case, and died at the local health center, thereby increasing the number of exposed individuals.  As of now, there have been 7 confirmed and suspected cases, with 5 deaths.

If nothing else, the string of recent outbreaks ensured that the infrastructure necessary to respond to the most recent outbreak was in place.  There were pre-existing isolation facilities at several hospitals (including Mulago Hospital, here in Kampala), and international expertise (from the likes of the CDC, MSF, etc.) to help coordinate a response.  The most recent outbreak was quickly contained, and really limited to family members of the index case and their immediate caretakers. Outbreak control is done primarily by 1) isolation of known or suspected patients, and 2) contact tracing for known contacts of patients.  Essentially, if you had contact with a case but are asymptomatic, someone checks up on you every day. If you develop any symptoms, you're off to isolation.

But I expect that the question on everyone's mind is - what is it like being here during an outbreak? Well, I'm sorry to disappoint, but the answer is - it's the same as before.  Although these are scary diseases, the rapidity of the initial response ensured that Ebola patients were not showing up on the wards at Mulago hospital. I think there were 2 suspicious cases seen in the Emergency Department, who were quickly rushed to isolation, though they both ultimately they received alternative diagnoses.  As such, during this outbreak, the only Ebola patients at Mulago hospital were known contacts who were taken directly to the separate isolation area (located in a cluster of tents set up in a fenced off area behind the hospital).  So I cannot feign bravery or altruism in deciding to stay here - it just didn't come up.  If there had been Ebola cases popping up on the wards, that would have been a different story.

As one of the senior physicians here put it, Ebola is not a "smart disease."  If you want to be successful, be indolent - like HIV - infect millions before we know what happened.  But if you just go and kill your host in a few fever-ridden days!? You won't make it very far.

Luckily, this outbreak hasn't made it very far.  Here's hoping it stays that way.

180 degree panorama of Murchison Falls - of The African Queen fame, Northwest Uganda

Perspective on Assault from Kla

Hello and Greetings from Kampala (it is often abbreviated kla)!

I've been back in Uganda working at Mulago hospital for almost 4 weeks now.  As usual it has taken me a while to find a chance to write a post, but I'm hoping to put up a few in the coming days to catch everyone up.

At some point I'll put together a post on the Ebola outbreak here (spoiler alert: I don't have Ebola), and another on the Quality Improvement project I'm working on putting together.  First, though, I wanted to write about some events that happened just before I came here to Kampala.

About a week and a half before I came back to Kampala, I was the victim of an assault in New Haven. It was midnight, and I was walking from a friend's apartment to my car in one of New Haven's nicer residential neighborhoods. I was walking with a friend of mine (also a resident). Although our cars were only about 2 blocks away from our friend's apartment, as we walked we crossed paths with a large group of adolescents.  There were a lot of them - probably 20 or more - all looked to be teenagers (from younger to older), and the group consisted of boys and girls, some walking, some on bikes, and all talking, chattering and interacting amongst themselves as the walked down the street.  Although it was an odd scene, they were not overtly threatening.  We had actually walked through the group without incident (they were heading one way down the street, and we in the other), but moments after we had passed them a smaller group of about 5 boys, mostly wearing ski masks, returned and assaulted us.

I didn't really see my attackers because they ran up from behind me and began hitting me in the head. I didn't realize it at the time, though in retrospect, and given the degree of the injuries they caused, we ultimately think they were hitting me with rocks. While three of the boys attacked me, another two snatched my friend's purse, shoving her to the ground and hitting her once (without causing significant injuries). They made no effort to rob me (my wallet and phone were in my pockets).

I was dazed as everything occurred, but as I was receiving repeated blows from behind, I decided to try to turn around to face my attacker, in the hope that a face to face confrontation might dissuade them.  Frankly, at the time, I didn't realize the gravity of what was happening, and I half thought that I would turn around and see one punk kid who had punched me a few times and gone running. Instead I saw several adolescents in ski masks standing behind me. I think the fact that I did turn around and face them was unexpected, and everyone stood still for a moment.

I saw that my friend was okay, and was not being pursued by anyone, so I kind turned around and sort of jogged and stumbled off into the adjacent city park (a few blocks of lawn and trees in the middle of this generally pleasant neighborhood). I could see that my friend was moving off in the same direction, and seemed okay. I could also see that one of the assailants followed me into the park, and I thought I saw him stoop to pick up a rock (or perhaps he already had one in his hand). I was not moving very fast (as you can imagine), so he was quite close behind me. I thought he was going to throw the rock at me (not realizing that they had already been hitting me with them), so I tried to bob and weave a bit, though lost my balance and fell to my knees. I expected another blow, as I tried to stand up, though I never received one. My friend later told me that the final attacker left me in part due to the shouted warning of one of the other assailants - something along the lines of 'what are you thinking? let's go!'

Although we were left alone at that point, moments later the same group attacked another resident just down the block who was heading to the same apartment we had just come from.

I only realized the degrees of my injuries as we waited for the ambulance. I had large lacerations on my scalp, my right forehead, and my right eyebrow.  My nose was broken and somewhat crooked. My most significant injury was to my left ear. A decently sized piece (about 1-1.5cm wide and about 2-3cm long) of my ear had been avulsed, and remained attached only by a sliver of skin near the very top of my ear. I have some great pictures from the ER, though even for a blog where I photo-documented cutting a parasite out of my own toe, they are a little much.  If you want to see them, email me.

As I write this, 5 or 6 weeks later, my injuries are all but healed.  I will have bit of a jagged Harry Potter-like scar on my right forehead, though the one in my eyebrow is largely hidden.  I went to the operating room about 5 days after the event to have an ENT doc straighten my nose, without complications.  And my ear, the survival of which was initially in question, ultimately regained its blood supply and has healed well (though the avulsed portion remains numb and there is a large scar).

I don't have too much to say about the higher meaning of the events at this point, in part because I'm tired of talking about them.  But I think I summed it up well, a day after the event, when I said: Random Violence is Bad.  I don't mean to say that all of this doesn't tell us something about the underlying problems of our society, but for those of us who are confronted with the results of poverty and hopelessness on a regular basis in the hospital, I'm not sure it tells us anything we didn't already know. Sure - I won't give large groups of adolescents in New Haven the benefit of the doubt on a dark street anymore, but I don't think that is a widely applicable lesson.

And what does this have to do with my trip to Kampala?  Well, in a way, coming back to Kampala rescued me from the aftermath of this event, in both a practical, and a philosophical sense.

After the assault, I spent about a week milling about at home, supposedly resting my brain after it was concussed -- which I am quite bad at -- and feeling generally restless. Even after the immediate medical issues were taken care of, it was difficult to overcome the inertia of the event - it had stopped my life. Every chance meeting with an acquaintance required another retelling of the episode, and my email inbox was backlogged with correspondance related to the assault.  Kampala, in that respect, was an escape. And while a quick trip to Uganda probably doesn't seem normal to many of you, I have done my best to make international work a regular part of my life, and so making it here was part of making it back to my normal.

And certainly, I did have to tell the story to a few Ugandans when they inquired about the wound on my forehead, though here the incident was largely forgotten.  It goes without saying, of course, that Ugandans are uniformly shocked that something like this could happen in the US. Interestingly, I found that Ugandans often had more difficulty wrapping their heads around it than Americans. While saying something like 'teenagers looking to wreak havoc' was generally enough of an explanation in the US, it is not sufficient here. Were they on drugs? Were they psychologically disturbed? A robbery would be one thing, or even a rebel army kidnapping children and raping and killing civilians - those are somehow more familiar here. That is not the case for truly random violence; in that category the US seems to stand out.

But Kampala rescued me from the implications of my assault in another way as well -- by putting them in perspective. I began this period at Mulago hospital working in the Intensive Care Unit. The difficulties of this work would fill a blog entry on its own, but suffice it to say that the ICU is full of unlucky people - victims of motor vehicle accidents (mostly from the motorcycle taxis), victims of assault (though rarely random), and victims of disease - people whose injuries are far worse than mine, who receive far less support and care, and many of whom don't survive. Walking past the emergency department, at any given time, you are liable to see a few patients far more disfigured than I was on my worst day, and who are unlikely to be helped to heal as much as I was.

It is easy to say to yourself "I'm lucky it wasn't worse" and then to go on feeling sad at just how bad it was. Living and working in a place where you are regularly confronted by "worse,"however, illuminates that type of sorrow in a harsh light.

Thanks to EgyptAir for having a pre-arranged tour to Giza for those of us with a few hours to kill in Cairo en route.

The Wide View

Since I got home about a week and a half ago, I've been meaning to put up another post about my trip. But rather than rambling I spent today putting together some panoramic shots I took.  That is to say that, using my Iphone, I took a bunch of contiguous photos and today I used a nifty program called Hugin to stitch them together.  Here are the results.

Kampala from the spire of the Qadaffi Mosque.  Don't be fooled, this photo is wrap around - probably not quite 270 degrees, but well over 180.

A Highlight of the trip, and easily one of my favorite all time spots - The Bulungula Backpackers in the Eastern Cape, South Africa.  Check out www.bulungula.com to get a sense.  This shot is probably about 270 degrees around.

The Beach at the mouth of the Bulungula River.  Nice place for a run.

 Sunset horseback ride through the community around the Bulungula.

Capetown from the top of Table Mountain. In the bay you can make out Robben Island, where Mandela was imprisoned for decades. If you're going to hike Table Mountain, I suggest packing a bottle of wine, a baguette, and a hunk of cheese. Picnic with a view.

 The Cape of Good Hope is on the left.

 A bit south of Capetown on the Atlantic Coast.

And one non-panorama for fun:

It was fun.

Incentives

What is it, do you think, that makes American physicians relatively good at their job? Actually, what is a physician's job? What is a physician supposed to do? I'm a resident - what is my job?  Is it to take care of patients?  Or to pass residency? Ideally the latter would be based on my ability to do the former - but what if it wasn't?

I've been thinking a lot about incentives recently - why do people do what they do? I tend to believe that there is always a reason, and moreover a reason that makes sense within the specific context. That is to say: a reason that makes sense given the incentive structure within which someone is working. With few exceptions, I generally assume that each individual makes decisions that they feel will be overall most beneficial for themselves or their loved ones. The upshot of this is that most people will act similarly in similar situations, given similar information and past experience (which accounts for culture and the rest).  So, if we assume broad similarities between individuals - that they share a similar knowledge base and background experience - then the thing that determines people's actions is largely external; it's the aspects of the world around each individual that make certain actions likely to be beneficial and others less so; it's the incentive structure within which each individual is operating.

Incentives, then, are a system's (be it cultural, social, religious, etc.) way of encouraging or discouraging certain behaviors.  That is actually be a bit too anthropomorphic, since, as often as not, systems incentivize behaviors very much unintentionally. The point is that, although individual variation is always at play, if you want to know why a group of people act they way they do, then look for the incentives.

So why do people at Mulago Hospital do what they do - or not do what you might expect them to do?
And what DO people at Mulago do?

Before I go into details, let me state the obvious - amongst physicians here, as in every location I have worked, there is no lack of intelligence, interest, or work ethic. Sometimes there is a lack of information, education, experience, and incentives, but not innate capacity.

Here is the cast of characters:

Consultants (who in the US are called Attendings) are the supervising faculty physicians. They're the ranking member of the team. Here, they are generally expected to show up for rounds twice per week, and while a few are present more often, it is not unusual for a consultant to show up once a week or less.

The Senior House Officers (SHOs) are the equivalent to our Residents. They have completed a general internship, and chosen to specialize in medicine. There are a variable number of SHOs assigned to a team at a given time. They usually have morning lectures, after which most of them show up for rounds between 930 and 10am. If they have other responsibilities, however, such as upcoming exams (which started this past week), they may not show up at all. If they are present, they are often the most senior members of the team, and they are therefore responsible for most of the medical decision making. Generally, they work on the wards until about 1pm. This means that most often they are only able to round of a portion of the team. After rounds, they are only occasionally present on the wards, but usually leave the intern by his or herself for the remainder of the day.


The lowly intern, as in most places, is the workhorse of the team. After medical school (which is six years, starting immediately after high school), comes internship. Internship is 2 years, during which the intern splits time between Medicine, Pediatrics, Surgery and OB/Gyn. On medicine, the intern generally arrives slightly before rounds (perhaps 830 or 9am), and is responsible for the daily grunt work - blood draws, procedures (lumbar punctures, thoracenteses, paracenteses), documentation, discharging patients, etc.. They are often not present for much of rounds, as they are pulled away by their patient responsibilities. Interns are not expected to see patients before rounds, routinely present patients, or determine management plans for patients when more senior members of the team are present.  They stay until their work is done for the day. As they are often the only ones present on the wards, they make many management decisions unsupervised.


As I mentioned, medical school here is on the British system - 6 years starting directly out of high school, with increasing clinical responsibilities in the latter years.  I have not seen a medical student since I arrived on either of the teams I've worked - renal or infectious diseases. I am told though, that they are around on other teams, and show up occasionally, though have little responsibility or clinical acumen with which to contribute to daily rounds. They are mostly occupied by lectures and other educational requirements.

As I mentioned above, we have just entered an exam period for the SHOs and medical students. During this time the SHOs and medical students are not expected to be on the wards, and the consultants are busy organizing and administering exams.  So, by process of elimination, that leaves the interns to run the wards by themselves.

So. Why do do these people do the things they do?

Well, there are a lot of reasons. Lets start at the top, and think about incentives.

For consultants, there is little incentive to work at Mulago Hospital at all.  It is the main academic teaching hospital in the country, which does hold some prestige. However, as it is bankrolled my the Ministry of Health (MoH), the salaries are a pittance.  One consultant told me that his base salary was only sufficient to pay for his transportation costs too and from the hospital each month - gas and no more.  So what are consultants doing with the rest of their time?  They're working other jobs.  They receive additional salaries from research projects, consultancies or other private practice activities. The MoH has made efforts to decrease the degree to which their employees work elsewhere, but you can imagine how well this works when they don't pay a competitive wage, and when it doesn't seem to eliminate pursuing research and other grant funded work that remains affiliated with the MoH.

In the past, it was not uncommon for nurses to work multiple jobs either - they might have a job on the wards at Mulago, another with a research project, and a third at a private clinic.  A few years ago the MoH cracked down on the nurses, and required them to choose either their MoH or their outside work.  The result was that the vast majority of nurses chose their non-MoH jobs, which were better paying, and now at Mulago there is often one nurse for a ward of 50 or more patients.

Back to the Consultants, though.  As I said, there aren't a lot of clear positive incentives for showing up to work at Mulago.  What about negative incentives for not showing up?  As far as I can tell, consultants receive little negative feedback, and no punishment for absences from the wards. One significant negative incentive that is always at play in the US is the threat of malpractice actions.  If an Attending physician in the US didn't show for a single day (let alone a week) and a patient had a bad outcome (let alone died) they would be held directly accountable, if not by an actual malpractice suit, by a hospital administration which self-monitors to manage its risk.  Not so in Uganda.  I've been told that the malpractice law here is strong - that it is essentially copied from the British law codes. Patient education, and expectations regarding the outcomes of medical care, however, are such that malpractice suits are unheard of except in the most extreme of circumstances.  For example, a malpractice case that made the media a few years ago was about a patient who, years before, had appendicitis and underwent an appendectomy. The patient later had recurrent severe abdominal pain, which ultimately led to an exploratory laparotomy by a different surgeon. The second surgeon found an inflamed appendix still very much in place. Apparently the original surgeon had done enough to leave a surgical scar, but had not actually taken the appendix.

On to the Senior House Officers. How many residents in the US do you think would show up for work if they were unpaid for the duration of their residency? A few? What about if they had to pay out of pocket to be allowed to work at the hospital?  That is the situation here.  House Officers have to pay the equivalent of a few thousand dollars a year (which is a lot of money here) for the privilege of post-graduate education at the hospital.  Still, they do it, and they show up - sometimes.  Let me put it another way: House Officers always show up for their exams, because failing an exam means failing residency. House Officers sometimes show up on the wards because absence has few consequences. Technically, they are required to be there, and you can learn some of the relevant exam information as you go, but given a lack of incentives to the contrary, if exams are approaching, or if there is anything else to do (like working that other job that you need to keep your family alive and pay for your residency), you won't find them on the wards. After all - most of the time, there is no consultant there to note their absence anyway.

That brings us to another concept that I learned here - Guilty Marks. Guilty Marks are the high grades that Consultants give to their medical students, interns, and house officers, when they were not actually present on the wards sufficiently to evaluate them.  I was told about guilty marks in a discussion of medical students. A Consultant noted that there is recent dissatisfaction with the quality of the medical students recently being produced at Mulago. He noted that the new interns coming from the other teaching hospitals in the country tended to be better than those coming from Mulago, although their institutions may have been less prestigious. In part, he blamed recent changes to the curriculum which has progressively decreased the students' time on the wards, to the point where they are sometimes not capable of appropriately interviewing and examining a patient. That is clearly a problem, but it's also a problem that these students continue to graduate.  And how?  Guilty Marks. If you are a Consultant on the wards, and you are called upon to evaluate a medical student who you were never there to evaluate - could you fail them?  Moreover, I'm told that if students don't receive quite high marks, they are liable to make life difficult for the Consultant by bringing attention to that their absence from the ward.  So, as it stands, medical students' presence or proficiency on the wards has little to do with their ability to graduate. So you will find them in the library studying for the next exams.

Finally, there are the interns.  Interns in Uganda are actually paid, and they earn what little salary they receive. With the exception of morning rounds (if an SHO or consultant shows up), the intern is left alone to manage anywhere from 20-50 patients for the remainder of the day. The patients tend to be very sick, and they are required to manage them with minimal resources and often no supervision.  How long would it take you to do 20 blood draws? And remember that probably 10-15 of them are HIV positive, so don't rush too much. And what about the Lumbar Punctures? And the documentation? And the patient who just died? and the new one who just showed up? and the one who wants to go home if you'll just finish the paperwork? And what about the lab results you have to walk to the lab for? and the 20 patients that were never reviewed on rounds - what do you want to do with them?

As you can imagine, the major incentive for the intern is survival.  Not for their patients, but for themselves. Interns do what they have to do to make it through the day. They do their best to manage patients by themselves when they have to, but there is no feedback on their management decisions. If a patient dies, then they die - it's a common occurrence. There is rarely anyone there to tell them what they could have done differently, if anything.  So they just keep doing what they can.

It's a tough system.

One of the first things that I noticed when I started thinking about incentives, was that no one seemed focused on patient care and there were few incentives to be.  Sure, they provide patient care, but sometimes it seems like an afterthought. The consultants provide care when they are present, but most often they're elsewhere. The same goes for the SHOs. And the interns do what they can to survive.  The contrast with the avowed goals and incentive structure of US medicine is stark - we are obsessively preoccupied with patient outcomes - length of stay, readmission rate, door to balloon time, catheter associated infections, ventilatory associated pneumonias, quality adjusted life years, mortality, and even subjective patient satisfaction. It is definitely the case that working in a resource rich environment makes focusing on these outcomes easier.  After all, who is going to focus on length of stay in a hospital in which half of your patients will die regardless of how well you manage them. But even though a focus on clinical care and patient outcomes tends to come with resource availability, I do not believe that it is dependent on it. Rather, it is dependent on the incentive structures in place.

If the system recognizes and incentivizes good clinical patient care, there will be more of it. If the system disincentivizes absenteeism, poor patient care, and excess mortality, then there will be less of it.

The question is, how do you do it given the current system, and with the resources and leverage at hand?

Any ideas?

Old?

It is possible that I am not as young as I used to be.  I'm not ready to make any absolute conclusions, but anything is possible.

It's been a rough few weeks for my body since I arrived.

On my first weekend in Kampala -- wandering around the city as is my wont -- I tripped.  Not a big deal really, but as I was in a rather busy pedestrian area of downtown kampala, and eyes are always on you, I tried to play it off as best I could -- just a stumble and kept walking.  It became tough to play off, though, when my flip flop started to fill with blood.  You see, as in many parts of sub-saharan africa, the sidewalk maintenance in Kampala leaves something to be desired. It is not wholly unusual to find almost anything jutting out of the ground - most commonly little twisted pieces of metal from old street signs or some such that were long ago driven over. While I didn't see exactly what caused me to trip, I have to assume it was one of these little guys that took a decent sized little chunk out of the tip of my left big toe.  

When I started to feel a warm, somewhat sticky sensation with each step, I knew what to expect when I looked down. I was impressed, however, with the flow rate.  Luckily, like any good traveler, I had toilet paper with me.  I wrapped my toe as best I could (though it quickly soaked through) and walked to the nearest pharmacy (only a block away). The folks there were very friendly, and after selling me bandages, tape, and an exorbitantly priced tube of providone-iodine ointment, they allowed me to use their scissors and sit on a bench inside the pharmacy to dress my wound while everyone watched intently. They also offered helpful advice like: 'be sure to wash that when you get home' and 'cut off that little hanging piece with a razor.'

By now the toe is healed.  And don't worry - my tetanus shots are up to date.  But it was an inauspicious start.

As soon as I was fairly certain that my toe wound wouldn't open up, I started running again.  Jogging in foreign places is one of my favorite things - no better way to explore new territory or confuse people who rarely see mzungu (white people), let alone running sweaty mzungu. I'd like to tell myself it's just that I was too exuberant in my exercise regimen, but whatever the reason, I started to develop a sharp pain in my left heel and the bilateral 2-3rd metatarsal areas.  Some of you may know that I run in those funny finger shoes, called Vibram Five Fingers.  They kind of make you feel like you're running barefoot, and I've always felt more aware of my running experience in them.  It's not always comfortable if you're running on a rocky surface, but overall I like it.

Barefoot running is a bit of a craze right now.  Proponents say that, rather than being hard on your feet, barefoot running actually forces you to change your stride in way which, ultimately, decreased injury.  The idea is that, because we are now accustomed to exercise in shoes with impressive amounts of heel cushioning, we learn to run with a heel-toe foot strike.  Biomechanically this transmits all the impact force directly up the leg into the knee, hip and back.  The ideal barefoot running technique, on the other hand, requires your foot strike be rather flat, or even completely on the forefoot, thus allowing the fascia, joints, and muscles of the foot to absorb the impact.  Decreasing the shoe padding also makes you more aware of the force of your impact, so you naturally land with lighter footfalls. Decreasing the support of the shoe allows more free movement of foot itself in response to terrain, requiring the use of your (now atrophied, though supposedly salvageable) intrinsic foot musculature, which, when healthy, is part of what decreases the incidence of running-related injuries, such as stress fractures, and plantar fasciitis.  You can read all about it in a very interesting book called Born To Run - a book about ultra-marathoners and a lost tribe of Mexican-Indian running savants - which I was in the process of reading when I, ironically, developed plantar fasciitis from running around Kampala in my barefoot shoes.

Sadly (for a runner anyway) the only real way to improve plantar fasciitis is to stop doing the thing that is causing it - running.  So I begrudgingly decided to take some time off, and when I restarted, to use the somewhat more padded sneakers that I have here.  It didn't seem like a big deal, regardless, as I was about to hop in a car for a 5 day trip to Rwanda and probably wouldn't have time to run much anyway.  I was traveling with a bunch of Yale medical students and a few other residents (from Stanford and UCSF) who are also working at Mulago hospital.  I had already been to Rwanda during previous galavanting in 2009, and remember it as a lovely place. So although I wasn't planning to go Gorilla Trekking again, I was happy to go along for the ride.

It was a lovely weekend!  Our first night was at Lake Bunyonyi in southwestern Uganda, just near the border with Rwanda.

Our second night was in northwest Rwanda, to let my travel-mates gorilla trek.  

After that it was off to Kigali for a few days and then back to Uganda.  Sadly, in Kigali, I met a buffet that I couldn't handle.  At least I'm pretty sure it was the buffet.  In fact, I think it was specifically the creamed spinach - the creamed spinach in which I mysteriously found an entire vertebrae (probably goat, by the size of it).  Surprisingly my GI symptoms were initially minimal, though the next day I developed fatigue, myalgias, fevers, and was sweating bullets -- all this while spending a day visiting genocide memorials.  Sounds cheery, right?  Perhaps my only bit of luck was that my symptoms were significantly improved the next day (for our 12 hour drive back to kampala) and my frank traveler's diarrhea didn't start until another day later.  Sometimes you gotta look on the bright side!

It wasn't actually that bad a bout, as things go, except that it was complicated by the terrible URI that I caught from one of my fellow travelers.  Sadly, some viral respiratory infection had found its way to a few of my fellow students/residents.  It started with a mild sore throat, then develops into a nasty head cold with flu-like systemic symptoms, and leaves you with a nasty sounding wet cough as your symptoms improve.  I was the third to develop this series of symptoms, and they hit me on the day we got back to Kampala - just about when my loose stool really kicked into gear.

So yeah.  My body has seen better days.  But I'm happy to say that as of today (about 5 days since we got back to Kampala from our trip), my toe is healed, my heel doesn't hurt (as clearly I haven't been running), my stomach has settled, and my cold is resolving.  And after it all, I can say that I'm resistant to another 2 (or more) African diseases.  Just checking them off the list.

Next post I'll tell you a bit more about the hospital and the rest...

Mulago Hospital, Uganda, Kampala

Hi all!

I'm off galavanting again.  This time I have been lucky enough to join a program affiliated with Yale called the Johnson and Johnson International Clinical Scholars Program, which allows me to come and work at a large teaching hospital here in Kampala, Uganda, for 6 weeks.  I've just arrived. I'll be working predominantly on the medicine wards, and looking to find a little adventure on the side.

I'll keep you updated!

Click here for the lay of the land...

Ben