I’m gearing up for my second week at work here in Addis Ababa, and I haven’t posted anything yet about what my experience has been. So…if you’re interested…here goes.
This is my shared office…I’ve been using the desk on the left.
I am spending the next 10 months working for the department of obstetrics and gynecology at St. Paul Hospital and Millennium Medical College. This hospital was started by Emperor Haile Selassie for the express purpose of serving the underserved and providing carefree of charge. St. Paul, or Paulos, as the locals often call it, has continued to do that to this day. Some of what I’ve learned this week is that approximately 80% of the care provided is completely free, and the remainder is nearly so. 100% of the maternity care is free, though some more well-to-do families deliver there and help support the other care. St. Paul has the busiest labor ward of any hospital in the country, delivering approximately 1000 babies per month. There are only a few hospitals in the US that have comparable delivery rates. The department I’ve joined has been incredibly welcoming and warm. I am now the 25th OBGYN on faculty at St. Paul. There are about 5-6 who specialize in high risk obstetrics, or maternal fetal medicine (MFM), about 4-5 who specialize in gynecologic oncology (GYN/ONC), about 4 who specialize in reproductive endocrine and infertility (REI) and now 5 who are focused on family planning – 4 fellows and me!
In the US, specialists tend to mostly focus on their own narrower field. Here, it helps determine what clinics you staff, but everyone covers everything on call. I’m lucky that I’ve continued to do general gynecology and obstetrics in the states as a family planning specialist, so I’m only moderately terrified about staffing the labor ward here with all the high risk patients, or getting called to help with an acute surgery for disseminated pelvic tuberculosis, something that is quite common here (my colleague operated on a patient with this on Tuesday night).
Right now, I’m feeling pretty satisfied when I can find my way to the room where morning report is held every morning at 7:30! This is a conference where the residents and interns (6th year medical students) review every patient admitted in the prior 24 hours. It’s been incredibly helpful for me to attend and hear what the services are like, how the residents are managing these patients, and start to get a sense of what my work will be. Fortunately for me, medicine is, by convention, conducted in English (I am taking Amharic lessons, but my vocabulary is still limited to about 10-15 words, and none of them are related to asking a woman about her labor contractions). In spite of the fact that everyone is speaking in English, it’s still sometimes challenging to understand. I am getting more facile at the accent which is so different from my own, I’m starting to learn the different acronyms and abbreviations, but I have yet to find a solution for the whisper-level speaking voices of some of the interns. I asked a colleague why they spoke so softly, and he replied, “Well, they’ve been up all night, so their tired, and they’re afraid of us”. So for now, my only solution is to sit as close to the front of the table as I can to hear what is being presented.
This sign tells me where to go…if only I read fidel (Amharic alphabet)…
If only I was a cardiologist, I’d know where I was going
Another big difference from how medicine is practiced in the US is that residents essentially run the show. The “consultant”, or OBGYN faculty, is only really called if there is something REALLY crazy happening. Not for something straight-forward like an emergency cesarean delivery. That is not to say that there are no teaching opportunities, however. And given the sheer volume, my colleagues (and now I) stay very busy. From what I have seen so far, my colleagues are unbelievably dedicated, super smart with huge intellectual curiosity and commitment to evidence-based medicine. There has only been an OBGYN residency program at St. Paul for about 8 years – prior to that, there were only 2 OBGYNs in the whole department. The entire department and residency program is the brainchild of Dr. Abdulfetah (incidentally, the first MFM in the entire country of Ethiopia), a visionary who felt and still feels a deep commitment to providing excellent women’s health care. Part of his vision, and one of many examples of the commitment to the care provided here, is that the OBGYN faculty take call on nights and weekends – and St. Paul is the only public hospital and training program in the country where this happens. I feel unbelievably lucky to be working at this hospital and with these amazing doctors (and residents, and nurses and midwives and students…).
The family planning clinic where I’ll be doing much of my outpatient care is called the Michuu clinic – which means “comfort”. We see postpartum patients coming for routine care and contraception, we see patients remote from pregnancy who want contraception and we see patients who need abortions or who are experiencing pregnancy loss. I’ve seen probably 20 patients so far who presented for abortion care, and at least a third of them were raped. About a quarter were under 18 years old, and probably 10% there due to incest. It’s been a stark reminder of the power differential that exists between men and women here. Another sizable minority have lethal fetal anomalies, and another group have fetal abnormalities that might not be lethal in the US, but are in Ethiopia, given the capabilities and resources of the neonatal ICU here. A majority of patients choose medication management, not surgery, as there are huge cultural biases against procedures. We did see a very sick patient last week who really needed surgery, however, and the laminaria to prepare her cervix could not be found. I’m sure a big part of my job will be figuring out what is and is not available, then determining what I can accomplish using what’s there. I’m looking forward to the problem solving, and hopefully will also be able to help with some protocols and structural elements to make things easier for patients and providers.
Mekdes (one of the family planning fellows) in front of the Michuu clinic
Mekdes and I
