Hello again from Nepal. Things have
settled into a bit more of a routine here and I am now working full-time at
Life Line Hospital, where I will spend a total of 3 weeks. Clinical
responsibilities include rounding on the inpatient medicine wards inpatients
and working in the outpatient clinic (OPD). Census varies from 3-10
inpatients and 15-30 outpatients seen daily. The work is done by three
internal medicine physicians who divide the responsibilities (including
overnight call) equally. In Nepal, internal medicine is a subspecialty
that requires 3 post-graduate years of training. Physicians must first
complete 4.5 years of medical school to receive their MBBS, complete an intern
year, and pass the national exam medical exam. The applications with the top
10-20% of exam scores are eligible to complete a residency and become
consultants. As there are limited training spots in Nepal, people often
go overseas to China, India, or even the Philippines for advanced
training. Ideally, the physicians then return to Nepal to practice,
but often the lifestyle and pay in other countries is preferable and so the
physicians will stay in the country in which they train.
Often we come to tropical countries
to study the “glamorous” infectious diseases such as filariasis, leishmaniasis,
or malaria. However, this rotation has been a good reminder that
non-communicable disease has truly become a global epidemic. While I have
seen a number of TB patients, I have yet to care for a patient with malaria,
typhoid, or dengue. At least 60% of the patients in OPD present for
treatment of hypertension, diabetes, or hyperlipidemia and the chronic sequelae
associated with them. Inpatient admissions for hyperglycemia and
COPD exacerbationsm are common. Nepali physicians face universal
challenge of teaching the importance of chronic-disease management.
Unfortunately, all too often, patients will chose to treat their hypertension
with herbal medications and do not have the resources to use life-long
medications. Consequently, it is not uncommon to have patients
present with heart failure, strokes, or myocardial infarctions after years of
untreated hypertension or diabetes. The physicians spend much time with
counseling about the importance of ongoing medical management and state that
they are gradually seeing improvements in medication compliance and
understanding of chronic disease. However, they see this as an ongoing
challenge which will take years to improve and feel a responsibility to
continue the endless fight against disease.
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| Taking a break from clinic duties to watch the cricket world cup. (Yes, I have tried to Wikipedia my way to understanding the game at least three times. No, I still do not have any idea of what is going on.) |
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| The costs of basic laboratory and consulting services at Life Line Hospital. For reference: 100 rupees is about $1 USD. |
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| A view of the outpatient department courtyard. |
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| One of the physicians teaching some medical officer students during a busy emergency department shift. |
