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...