Thursday Jaws, sorry about the pun. Actually, I don’t think the lion (Ginger) thought it was very funny.
This sounds like an examination question! Recently I have been working in the community as a general practitioner, a family doctor, here in the United Kingdom. I must do this for at least a month each year in order to retain my medical licence, without which I would be unable to work overseas. Also, I need to have an annual appraisal and every five years the UK’s General Medical Council considers whether to revalidate my licence.
Five similarities between working in primary care in the UK and Zambia
1 Not all my patients speak English
I enjoy being able to consult in English, but having said that, about half of my patients here don’t speak it as a first language. This is because I work in an inner city, a very cosmopolitan area. 95% of the time, I manage to get by with a limited vocabulary and basic grammar, but I still need an interpreter for a few patients.
This can cause some administrative problems, because of the revalidation requirement to collect anonymised, written feedback from at least 35 consecutive patients. This isn’t easy if some of my patients (in the UK) can’t speak or read English well.
In contrast, only 10% of my Zambian patients speak English fluently enough for me to consult effectively. These are mostly the well-educated and well off. I don’t want to be restricted to caring for the most privileged, so I always try to work with a Zambian nurse or clinical officer. They take a history from the patient and we discuss their clinical management. It turns the consultation into a useful teaching exercise.
2 Lack of free medication
It was frustrating to be unable to prescribe common medication in both countries, for cost reasons. In the UK, NHS prescribing for about 75% of the population used to be free. However, many of the most frequently prescribed medications, such as simple painkillers, antihistamines, antibiotic eye ointment and certain skin creams are no longer free; patients have to buy these products from a pharmacy or a supermarket.
In Zambia, medication prescribed at a health centre is free, but in such short supply that the range of drugs is very limited. Occasionally the health centre ran out of basic items like paracetamol and intravenous fluids. I would regularly write out a private prescription for the patient to take to a pharmacy in Mfuwe or Chipata.
3 Restricted prescribing
In UK primary care, all medical records are computerised. Sometimes, when I decided a patient needed a certain drug, the computer would try to change my mind. “Try this form (tablet, capsule, syrup) of the drug, it is cheaper.” Or I would be urged to switch to a similar drug, which might have fewer side effects or is less likely to interact with other drugs. The computer might not think I was competent to prescribe a drug (even though I know that this is what a specialist would prescribe if I were to refer the patient to hospital). GPs and specialist pharmacists have produced treatment algorithms and guidelines based on clinical evidence and if I don’t follow it religiously, I will be asked to explain why. I may be censured if my explanations are not considered good enough.
Sometimes the patient tells me that they have already tried the drug recommended by the computer and it hasn’t worked or they cannot tolerate it. Or it interacts with another drug they are taking which has been prescribed by a hospital specialist, unknown to the computer.
Occasionally I reject the guidelines because the patient doesn’t like a drug’s taste or doesn’t want to take it in a gelatine capsule as they are vegetarian or it is considered”haram” or forbidden. Artificial intelligence tends to assume all patients are similar; I treat them all as individuals, sometimes quirky, but with valid opinions about their medical care.
In Zambia, certain essential drugs may not be available, particularly for non-communicable diseases. I had to beg a local charity to provide three months’ supply of haloperidol to treat the dozen or so patients suffering from severe enduring mental illness in Mfuwe. We only had limited stocks of a tricyclic antidepressant with troublesome side effects (amitriptyline) even though fluoxetine (Prozac has been in common use in the UK for over 25 years) is cheap and well tolerated.
We had no insulin and oral medication for diabetes was often out of stock. We had no inhalers to treat asthma and had to use oral salbutamol tablets instead – an ineffective practice we stopped doing in the UK 50 years ago. The range of drugs to treat high blood pressure was very limited and stocks were often in short supply. We would occasionally run out of basic drugs to treat epilepsy.
4 Many patients consult with self-limiting illnesses
People in the UK and Zambia often seek medical advice because they think that they are unwell and that the doctor or nurse will be able to treat them. In both countries, care is free at the health centre or community clinic.
In the UK, patients with a cold or viral upper respiratory tract infection will have often tried taking simple preparations, either traditional (tamarind, honey, chilli and lemon juice, any combination) remedies or cough syrups from the pharmacy for several days with no resolution to their symptoms. Some patients feel their symptoms are so severe that they need treatment with antibiotics. Others would prefer to avoid antibiotics but consult to see if the doctor thinks they need them.
In Zambia, patients with minor self-limiting illness expect to be given medication, and often resent being given a scientific explanation why antibiotics won’t work. Traditional healers (sangomas) understand the value of placebos and encourage the patient to return, as this is how they make money.
In both countries, with easy, free access to healthcare, patients often have a low threshold for seeking advice. One of my patients in the UK brought in her infant son because he had been awake from 2am to 4am that morning. A patient in Zambia brought in her daughter because she had vomited once just an hour previously.
5 Obstacles to referring patients to specialists
In the health centre in UK where I have been working, it is reassuring to have hordes of specialists in our three city hospitals available to see patients who require further investigations or surgical procedures.
Twenty years ago, I knew most of the hospital specialists and could write a personal referral letter. I knew that Ms A was the best orthopaedic surgeon for shoulder problems, Mr S was the best gynaecologist for patients whom I thought did NOT require a hysterectomy, for example. The consultant would read the letter and decide on how quickly they should see the patient based on the quality of information in the letter. Those days are long gone in the NHS.
Now I have to use a complicated referral system called PRISM which leads me through a box-ticking pathway of algorithms to ensure that my patients meet strict referral criteria. For example, if the patient is 64, not 65 years old, or if I haven’t prescribed drug X, my referral could be rejected.
This approach stops whimsical referrals from GPs (in the past, some might just write, “Dear Dr, please see and do the needful.”) but it erects barriers for patients to access specialist care. I think that limiting access in this way amounts to rationing care.
There is an express “Two-Week Wait” referral for patients who might have cancer but they must meet even stricter referral criteria. Not all patients meeting the criteria are found to be suffering from cancer (about 15-20% are) but conversely, some patients who don’t meet the criteria are found to be suffering from cancer when they eventually see a specialist several months after the GP referred them. Perhaps this is why Cancer Research UK recently revealed that cancers are diagnosed later in the UK than other comparable European countries.
In rural Zambia, if we don’t have the resources or expertise to treat a patient, we can refer that patient to hospital. This may not be as simple as it sounds. The nearest district hospital was 50 kilometres away, manned by a single junior doctor assisted by a modest number of nurses and midwives. The provincial hospital had more staff but was 150 kilometres away. There was a very limited supply of fuel for ambulance transport in emergencies, so most patients (or their families) had to pay for private vehicles to take them to hospital.
There is a strict referral pathway, clinic to health centre to district hospital to provincial hospital to University Teaching Hospital in the capital, Lusaka. If I wanted to refer directly, I could telephone the District Health Officer or a specialist at UTH in exceptional circumstances, such as childhood cancer or leukaemia.
And one difference, consulting children
I enjoy interacting with patients wherever I am. I am touched by the Zambian children who wear their best clothes to come to the community clinic or health centre. They are much quieter and more reserved than children who see me in the UK. They are usually mute and refuse to describe their symptoms in their local language. They stare fearfully at the strange muzungu doctor, like rabbits at night caught in the headlights. Their parents tell their stories for them, not always reliably. “My son has a headache,” they might say because the child has a fever and has been crying. They don’t understand the need to answer detailed questions because they view the doctor as omniscient, like any traditional healer or sangoma.
Children at the health centre in the UK tend to be more communicative and occasionally rather naughty. A mother brought her infant and two older children to the health centre, and while I was examining the infant, the other children started jumping up and down on my examination couch.
Their mother said, “I’m sorry doctor, but they were behaving so badly outside, I told them that the closed-circuit TV camera would have recorded it all and they would be punished by being forced to spend the night in the health centre.”
I replied, “So that’s why they are trying out the bed, is it?”