Systems

I had a conversation with a Mulago resident today. He was telling me about how at a public hospital the physicians make around $600/month starting salary. In the private sector a physician can make that much from a single surgery but it's hard to find a job/patients that way. What many of them will do is start off a Mulago hospital and simultaneously work as much as they can in the private sector. This means that many physicians will just come for 2-3 hours a day and leave. It doesn't matter how many patients they see (or don't see) on the Mulago wards but in the private sector the more patients they see the more money they make. You can't blame the doctor.. $600 is not enough to cover the cost of living in one month.

Inefficiency and lack of organization has been a recurring theme over the last couple of weeks. The bureaucracy leading to unnecessary paper work, the lack of a reliable and efficient way to order tests and treatments, the lack of efficient triage. I was outside the Emergency Department today when I saw a police truck pull up. The policemen walked in and brought out a stretcher. The opened the back of the truck where there were rows of seats (empty seats). They pulled a woman from under those seats and put her on the stretcher. When they entered the Emergency room the brought her to the main patient area and put her on the floor. A discussion went on for 15 minutes about what had happened to her and what they should do. It looked like she had been hit (in most likely a boda boda accident). She had abrasions on her trunk, arm, head, and back and was not very responsive to questions. They finally get her onto a bed and a few nurses come to clean up the blood. No doctor had seen the patient yet. The nurse cleans around the wounds and then proceeds to suture the lacerations. It's interesting what is prioritized in this kind of situation. The lacerations are closed but no abdominal ultrasound, chest XR, or even neurologic exam is performed. I thought about NMH and the protocols we have for a situation such as this one. The protocols we have for most situations and the simulations we run for practice.

I think here it is not so much a lack of resources or a lack of knowledge-- as I had thought before I came. The doctors are competent, there are most necessary supplies. It seems to be a systems-based problem. There is no organization of resources whether it be doctors, nurses, or medical supplies. The doctors have no incentive to work particularly hard and are not regulated. Sometimes when there are resources they're not allocated to the right areas (for example, on OB if we need suture for an episiotomy repair, there is none available on the wards because it is all locked in the matrons office.. who is out for lunch). I'm not saying that they have all the resources or training they need... but I think what they do have is poorly and inefficiently managed. I never thought I'd think that managers/management was crucial-- after all, isn't that who companies cut first during a recession? I could see patients all day and bring as many supplies as I could carry.. but those things alone would not solve these systems issues. An overhaul in the management system would accomplish more for patients than I could ever do. Perhaps I'm finally understanding what my consultant friends do..?