Consultants and their Consultancies!

Time flies and is dead serious at its business of flying..

It feels just like the other day when me and a bunch of my colleagues were being oriented as college freshers. Orientation meant observing, asking and helping out wherever it was one happened to be placed but one had to eventually graduate from being a hand person to an actual doer. The one month was meant to prepare us for what it was that we were getting ourselves into. I remember one very good friend of mine who used to faint away at the sight and smell from a very bad wound in the male surgical ward. But he has gone on to make a world class anaesthiologist!

Observing was the best part for most of us, the more aggressive and daring were however able to establish their competencies early enough during this period. My very good friend C developed a particular affinity for maternity and went on to be a small authority on matters obsgyn in our class..

Overall everybody was able to pick some small trick or the other from the people we had to work under. Well if you had to be mentored by guys like Dr. O, you had no choice. O was a specialist surgeon. He provided my very first up close experience with a consultant, that department happening to be my first placement. Pompous in style, he was known to make it clear to you that his knowledge well ran deep indeed. He gave instructions concisely, precisely and eloquently in a style that was only his. Known to be a bit too laid back in the wider scheme of things, he ingrained in most of us the idea of a doctor's (especially surgeons) self worth as being well superior to the other medical professions. He was eccentric just as he was a genial being at heart. One day during a tiresome operation (I can't recall what) he happened to cut himself through the gloves and to the utter shock and disbelief of his assistants went on unperturbed to the completion of the procedure. All pleas to change gloves fell on deaf ears. Now that patient happened to be HIV positive. Did he then deserve what befell him? For he succumbed to the very same HIV some years later. But had he taken precautions would the world be less one good surgeon?
We were also acquainted with a certain Dr. OO. A physician who actually believed that books treat patients. His customer care relations was a phenomenal disaster and it's why his private private practice was not only a case study on how not to run a private practice but how not to relate with people. It was hard to believe he had not heard of or purposely disregarded a very simple Second Law of Medicine which stated thus; that patients did not care how much you know but only want to know how much you care. Lacking in that universal element called empathy he only made a good ward round and lecture hall academic doctor but a bad actual doctor.

Then came internship. I remember vividly what a lovely mess our morning meetings used to be. The Med Sup who happened to be a consultant surgeon himself was always in a state of war with about everybody else. His most frequent combatant was one old general practitioner. Now this old good fellow was Russian trained and had lumbered on his practice and was coming to the sunset without the honor of a specialty. He was the most agreeable chap you would ever encounter but all this changed the moment Med Sup picked his unending wars with him. Then Good Old Fellow in a supreme defense to his ego could go hard at him. It always ended with one calling the other medieval, archaic and the other 'a surgeon and no doctor'.
The points of conflict were as varied as they were baffling; why do you still give frusemide in this day and age? Why can't you get your anatomy right? You are not going to patronize how I deal with my patients! And so forth and on. My own reading of things then was that the one was a poor master of logic whereas the other was a poor defender of his position. Just a small dose of modesty could take one far. These roles however kept swiftly changing from one to the other in the course of the many encounters they had.
It was clear Good Old Fellow could not stand the, ''I am a consultant you know'' attitude that Med Sup wielded mercilessly.
Then there was Dr. W! Now this guy was and still is a joke! If doctors have occasionally been accused of some unfounded queerness in character and personality then W is probably one of the reasons. He was the obstetrician gynecologist. He hardly attended any meetings with the rest of the team. He came late, most of the time drunk and he owed no one an explanation nor apology. Did he himself keep his appointments? He was known to engage in some out-of-nowhere banter that was discomfiting to some patients of his. Many were the times that a junior doctor was called in to go handle his clinic. I can not for sure say if 'The 48 Laws of Power' was the only book he read but the number of times he carried this book along with him are infinite. He believed himself to be the master but I believe his patients were the real masters for they made their displeasure known and eventually he had to be let go.

Good Old Fellow might have been in err but he had a point all the same. How many times have you had a physician say, ''I will now send you to Dr. D the diabetologist!'' Or a pediatrician proudly quip, ''I am not a physician!"
And so it was that after some reluctance I took the mother to a colleague friend of mine (who based abroad) to the resident physician of one of the high end treatment facilities in the country. With reluctance because I have come to understand how these people think and work and I wanted a different physician but they prevailed, for some reason to be seen shortly. The old lady in question has been hypertensive for close to a decade now. The blood pressures had however been under remarkable control. For some time she had also been on anti failure regimen. Then she developed a progressive swelling of the feet and weakness in the hip to the point that she could hardly move without support. Many tests done and nothing. The case was clearly confounding. Now this is where the Big Hospital Physician comes in; he was actually for the longest time the personal physician to the lady in question till around two years before when she chose a nearer (and cheaper) alternative. Much of what she had been on was however retained.
We fix the day and make all other arrangements me being engaged in some other businesses then. The day comes. Old Lady is one of those witty mamas off the old mold. I am more than adequately cracked up all the way to the hospital. Man, is she not a dose of talent, is she not therapy! Sometimes when I have only purposed to briefly check on her I have found myself spending an hour or two laughing and drinking off her ever flowing cup of wit, humor and reason. She will wait at the height of your mirth then whisper something in your ear, "I can see you want that lady but be forewarned, she will lick you dry!" Blessed with such a magnanimous heart it was heart rending that her physical heart was actually failing her.

The reception here is world class and so Mr Physician better be good too.
Appointment or new? New.
General doctor or Consultant? Consultant physician.
Okay, this way.
We find ourselves waiting in line at the physician's offices after the usual routines of registration and booking. Old Lady's turn comes and in she goes. One of those remarkable characteristics of good doctors is their uncanny ability to remember their patients. And so despite the bubbling queue outside about three minutes are spent in cheerful banter between the two; for old times sake. We then settle down into serious business and I state the details of the case. He carefully reviews her medications and asks and asks again one or two issues. Then he sits back in his chair and ponderously stares into the air. We (me and Old lady's son) let him do a thorough physical examination as we wait outside.
So doc how is she? I ask him when when we are re-admitted.
Damn I don't know! She seems to be on optimal therapy but I can't explain her weakness and edema.
Me: It's why we brought her back!
He: But you expect too much from me my friend.
Me: you are the physician! okay then, course of action?
He: (after some brief engrossment) let her do a chest xray.
Me: chest xray! but how useful is that? I believe it will only show an enlarged heart..
He: let us start there, it might show us more..
Me: what about her weakness and hip? Is not an MRI indicated?
He: let me see what the chest xray reveals first then we can do the others later.
Me: (out of sheer respect) okay doc.

We return with the chest xray film about an hour later. It shows us nothing much and so the physician at an apparent loss on how to proceed says this: she will continue with her current medication and i will prescribe some medicine(prescribes) that you will try to get outside since the hospital stock is run out. Then within two weeks kindly let me know(gives me business card) how she is doing.
What an epic underwhelment. But as leave the consultation I console myself with that Ralph Waldo Emerson; every man I meet is my superior in some way, of that I try to learn from him. In my case it's comforting that even the best of them get caught in quicksands.
All the renowned pharmacies in K had never stocked the mysterious magical elixir and so we end up right where we began, only about 15k less loaded than when we walked in that magnificent reception. When you grow up strive to be a consultant in something or the other..

Politicians On Call

The time was around eleven fifty something in the night. The three rough knocks on my door were unmistakable; it was the security officer. But it struck me as kinda odd. There was the hospital phone line that was supposed to come through; this was the agreed on system and for a long time it had never been flouted. But I still remembered this chap's trademark authoritative knock that would be rumble through the entire residence. I was in the middle of one of those MGM movies but had to suspend it. I was on call that week and this sort of thing was to be anticipated.
So I make my way to the door and ask the officer what the matter is.
"The Med Sup wants to see you daktari".
"Damnit, at this time?" "Is it over a patient?"
"Not a patient, the minister is here and they want your assistance."
"The minister! which minister?"
"The Minister of Health himself"
"Is the minister of health sick, I mean does he look sick?"
"Okay that I can not say, that is for you to establish."
"Okay then, I am on my way; let me get my stuff."

By this time I am fully alert and with rising curiosity turning over everything in my head. The minister who happens to be the local member of parliament is here, and he wants my help...!
Damn it, but the minister is known to spend nearly half of a minimum wage earner's salary on lunches at very serene addresses, why would he even bother to experience the well known inefficiencies of a public sub district hospital in the middle of the night! Exactly what does he expect to find? I brace myself for whatever.
So I discard my warm stylish jumper, put on my expected official attire, give the badass flick on the telly one last sorry glance and head out.

This was way before the new constitution was effected in 2010. Fast forward five years and devolved public healthcare is here; a mixed bag. There are some distinguished performers but across many other counties the tale is almost similar; perennial disorder and undermanagement. It's strike season reloaded..
Of course the general consensus across the healthcare professions has been the desire to revert this key sector to the national government. But while other hard boiled unions were lobbying for the retention of their functions by the national government these ones were in deep slumber! Not that devolution is a bad thing in itself but the experience so far points out the haphazard management of health and its functions by people who being neither medics nor proven managers for that matter only understand it from a consumption point of view. Supportive supervision is now replaced with patronizing supervision in most instances.

The matter has raised concern even up to the legislative arms of government but whether a complete or even partial return succeeds remains to be seen. But the factors for the poor showing have have been as diverse as varied. The governors are not taking this lying down and this is for well reasons...this is human nature in Third World Africa! But let's all wait and see.
Enough of the state of devolved healthcare for now though..

I head straight to the general admission ward. There I meet the nursing officer on duty and quickly inquire what the matter is. She confirms to me what I already know; that the minister is here and he is looking for some information about a particular patient!
"Sister, you can't possibly be serious!"
Do you mean me or the minister! If you don't believe it go to the records room, you are awaited there.
It takes me just a few minutes to the said records office outside of which are the official security officers of the midnight dignitary (poor souls are still on important national duty.) I enter and find the hospital Med Sup, the Nursing Officer in Charge, a harassed looking records officer (it's his lucky day of soberness!) and the hallowed guest; the Minister of Health himself. Both are standing except the records guy who has before him open registers from the outpatient, laboratory and from his own department.
I determine to shake hands with at least the minister but even before I take a couple of breaths in that room the Med Sup cuts to the chase. This is what he says; daktari sorry for the small bother. I know you young men switch off the moment your official hours end (his house and mine are within negligible proximity and so he must be well aware I keep late hours blasting Lords of The Undergrounds, Rakims, CL Smoothes, Gangstarrs, De la Souls et al)
Now you must recognize honorable minister here who also happens to be the area member of parliament.

"Yes I do." I notice the minister is surveying me with that lackadaisical, erudite air of muffled curiosity, is it my unshaven beard? Or that chronic look of distant distraction about me that has won me some unnamed trophies before?
Med Sup goes on; the minister sent a patient here earlier in the day (I surreptitiously glance at the wall clock in the room and it's just a few minutes past mid night!) and we can't seem to find any proper documentation about the patient, do you know anything about the said patient?
I request for the name. I vividly recall the man and say I do.
All the while the minister is harmlessly silent and hardly recognizable but I am on the lookout for his rather well known sharp wit.
"Now daktari we can't seem to trace any meaningful attention the patient received, why?" he breaks in in a slow measured baritone.
I believe it was all captured in his outpatient consultation booklet. And he was referred with it.
That is besides the point, why is there no record of the very same information in your registers?, he ferociously asks.
"Well that I can not definitively answer, I only do my bit and so I can not say why so and so did not do his part."
"Now that is a new one, this is supposed to be a system, it should work like clockwork, a person on every point of the chain should not only care for but actually know what happens at any other point."

By this time my energy is up and my agitation is climaxing but I keep my cool. It is all a situation I can handle but the Med Sup joins in the fray in this manner; "So you know about the patient, what happened?"
Okay the patient was a frail looking elderly man who came here yesterday in the morning. His chief complaint was a progressive growth in the abdomen. It has been there for close to a year now. And so when we reviewed him we thought it was most likely a malignancy and that is why we referred him to the provincial hospital for further work up.
"You mean even no simple test was done?"
"We did an HB on him and it was not low enough to warrant any immediate intervention."
"What was it?"
"It was ten."
"Was an HIV test done?"
"Yes but the result I can not disclose to other parties."
"That patient is my neighbour and it is me who sent him here, now was there nothing more you could do for him? Could you not have admitted him?"
"In his condition of presentation, nothing much and he had no current complaint to warrant an admission here, I am sorry to say that."
"Now daktari why was that patient kept here the whole day awaiting the said referral?"
"Our ambulance was out on other official hospital duties and the patient had no single coin on him, so he had to await his relatives who came very late."
I see, I will make a follow up the provincial hospital in the morning, bwana Med sup you are doing some good work here but I firmly believe you need to crack the whip on this leniency, records are invaluably important and if this is just one case how many others are missed this way?"
It is an issue we are working hard to fix, of course you realize how hard it is to keep everyone in check in a setting of this magnitude but overall i can say we are doing much better now.
"And we shall keep at it till we achieve perfection." This was from the Matron who all along had been a silent participator in the proceedings.
I believe this will be diligently done. Bwana Med Sup I am getting you a proper ambulance like I had promised. Will instruct the PS to effect it once I get back to Nairobi.
Oh that would be a great relief waziri. Our facility is breaking at the seams from activities and if we had an alternative means of transport such cases as this one would happen less.
This is the time for us to do as much as we can for our people. You know it is such an uncertain terrain that we traverse, so this is the time, let me see to it when I get to Nairobi but make it a point to remind me too.
Okay Bwana minister.
I quipped in, "You have yourself been a big proponent of social justice and equity but my observations tell me healthcare is still miles off in this respect. This makes the case for universal health insurance schemes even more dire."
That is correct, a particularly important and pet concern of mine. We have a team of consultants currently working on this very issue at the ministry and we expect that they give us their report and recommendations in a month or so. Then we can see how best to go about the whole issue.

A little more prattling on policy issues, developments, recommendations, projections and even politics followed that left me with a clearer conviction that he was still more suited for the lecture halls and university departments than he was for the rough tumble of government and politics.
The time was some minutes past one when everybody scattered into the night to their either warm or cold beds depending on each one's social arrangements! I personally headed straight to the homely couch, me being a notorious bachelor then.

The next day I woke up to the news, with obvious distortions of course about the minister's night call. Who had received a dress down or who was being moved or worse still who was being summarily dismissed. But lost in all the noise was what the minister meant by sending a poor neighbor of his to hospital utterly penniless and then making the follow up in the deep of the night. Only a few voices commended him for this, others condemned him for this funny guerrilla like operation. A honorable minister should move in light! And so on and on the buzz went on into the day.
It was unfortunate the old fellow succumbed a few months later having been diagnosed with cancer of the intestines which had aggressively spread in the later stages.

And so now in many facilities we have local politicians haranguing overworked, underpaid, unpromoted and yet to be paid healthcare providers. The discord between many county governments and the national government is not helping matters either. It is hilarious sometimes when these very uncivil elected or selected politicians want their relatives to receive particular treatment to the point of dictating the same to providers.
It happens that many of my colleagues in county government employ have to endure the wrath of internet educated MCAs or county executives imposingly asking them how for instance why if they can not diagnose or treat cancer then what good are they!

The promised ambulance never materialized!