Saturday, August 01, 2009


recently i spoke a bit about interaction with foreigners. the impression i left would have been strained to say the least. but as with all things there must be balance.

they were tourists (aren't they all?) when in the kruger she developed severe abdominal pain. her son brought her to hospital.

when they called me, besides the usual clinical history the casualties officer made a point of mentioning to me that they were american and that her son, the one who brought her in, was a physician. let me take a moment here just to mention a language difference between english and americaneese. in south african english, a physician is a specialist in internal medicine. in american, it seems, a physician is simply a doctor. at that time i did not know this. none of us did. so when the patient told us her son was a physician we all naturally assumed he was a physician and not just a common or garden variety md.

i mentally prepared myself for a confrontational family. usually with non medical first worlders they question you at every turn. a physician (south african definition) traditionally is sceptical of the knife happy surgeon. i couldn't help thinking of the internist in scrubs trying to protect his patient from the destructive steel of the blood crazed surgeons. all i could hope for was a benign abdominal cramp which would soon pass.

the patient was in pain. she associated her discomfort with some or other something she had eaten the previous day in the kruger. but it just seemed too severe. besides, could anything bad actually come out of the kruger? she had none of the signs which indicated that she needed immediate surgery. but the pain really bothered me. it nibbled away at the back of my mind. then came the x-rays. they were worrying. i was looking at a partial obstruction, but the bowel was just too distended. one more thing to quietly eat away at my mind.

then suddenly the son appeared as if out of nowhere. he greeted me in a friendly manner. i introduced myself as the surgeon. even after hearing who or rather what i was, he remained friendly. i remained guarded. afterall i was under the impression i had to do with a physician (when in actual fact i later found out he was only a doctor).

i showed him the x-rays. he could see they were not good. i then went on to tell him i was worried and i felt an operation was in order. at this stage let me mention that a partial bowel obstruction does not need t0 be operated immediately. it can be left for the next day. but in this case there were just a few too many things eating away quietly at my mind. i had a pretty good idea what this meant. he surprised me. he said that i should do whatever i thought was needed. i did.

the operation went as i expected. i expected necrotic bowel. i resected what was needed and did all the other things that us surgeons do in these circumstances. but when you have necrotic bowel, especially in people with a few years behind their names, the patients tend to be much sicker than they initially looked. this was no exception. we were worried about here generally and her hemodynamics and kidney function specifically. we were worried enough to send her to icu. the gas monkey even felt the need to leave her intubated. i concurred.

after i had tucked her into bed in icu i wondered where her son was. it was way after midnight so it was reasonable to expect him also to be neatly tucked into his own bed in one of the many guest houses in nelspruit. but i just felt i'd better check in the ward where his mother would have gone to if she hadn't ended up in icu. he was a colleague and besides, he might expect the worst if he found his mother in icu intubated unexpectedly. i took a stroll to the relevant ward.

i found him and his wife sitting in the scantily lit room where his mother should have ended up patiently waiting for her return. i smiled. i was starting to like them.

i greeted them warmly. i didn't want them to expect the worst. i then went on to explain that there had been necrotic bowel due to a twist of the bowel and therefore we felt it prudent rather to send her to icu. i reassured them that she was well and we expected no further unforeseen problems. i warned him that she would be intubated and reassured him we would probably wean the ventilator and extubate her the next day. he was pretty ok with everything but i could see in his eyes the normal amount of stress associated with hearing that your mother needed to be admitted to icu.

he put a stong face on it. he asked me a few questions and i did my best to reassure him on each point. then he asked a question i was afraid i would not be able to reassure him on.

"and when we go down to icu, will we be able to speak to the intensivist?"

"umm...errr....that would be me." after all, this was a peripheral town in south africa. in fact there is no real intensivist in our entire province. suddenly i felt sorry for these americans. they were far from home, their mother was very sick and the best they had to look after her in icu was a mere surgeon. there must have been at least some inkling of a misgiving in their minds. but he didn't show it. he smiled at me and simply said;

"ok. well we'll see you tomorrow morning then?" i was impressed.

the next morning i did not see them. they must have still been asleep after such a late night, i assumed. however the following few days their involvement really did leave an impression on me. it was also about this time that i realised he was not in fact a physician as i understood the word, but a doctor who was busy specialising in tropical diseases (or some such thing).

anyway the patient did well. she had the setback of a bit of wound sepsis which, considering everything, i could live with (although i have heard that some people in america want to put it onto a never event list?????). that was soon sorted out and after not too much time she was sent on her merry way.

this case also caused me to be contacted from the states. the patient herself sent a thank-you letter as soon as she got home, as did her son. she then sent a further thank you letter a year later and the year after that.

so, if i left the impression that i have my reservations about treating foreigners, please think of this delightful old lady and her equally wonderful family.


rlbates said...

I am happy to hear some American tourist can be so gracious. My kind of lady. :)

Jabulani said...

I am reminded of a line in the film Mrs Henderson Presents where Dame Judi Dench says of an American chap "You're American? Lovely manners, pity about the accent."

Europeans can be equally gracious; I've met several in the majorly touristy town where I live. Of course, I've also met several of similar ilk to the ones you earlier mentioned! Belgian or French mostly... ;)

shadowfax said...

i was under the impression i had to do with a physician (when in actual fact i later found out he was only a doctor).

I don't get the distinction, or at least I don't get the "only" part of it. Yes, in the US "physician" and "doctor" are more or less synonymous. But "only a doctor" is strange -- is a non-physician doctor less prestigious where you are?

I don't see a big difference in respect and stature between internists and other specialists. Internal medicine is above Family practice on the totem pole, maybe above pediatrics. Also below cardiology or neurology (possibly ER?). It's not some gloried thing.

(also, most infectious disease specialists did an internal medicine residency first.)

So, what's the pecking order down South?

Travis said...

I was also confused by the distinction. As an adult in the U.S., all of my doctors have been MDs who were board certified in Internal Medicine. It's not high or low in terms of prestige.

Is there a residency difference in South African for a physician vs. an MD?

sindz said...

South Africa is weird. There is a high premium placed on sepcializing. For example I finished my community service at the end of 2007. I am now working for an HIV/AIDS NGO. Most of my peers are in their first year of specializing. And everyone wants to know WHEN I'm going to the 'only a doctor' thing stems from that.

And trust me if you are a GP in're 'only a doctor'...and yet in my books they are the most important of all. Without them, how else would people end up at the specialists except via casualty?!

Bongi said...

in south africa you study for 6 years to become a doctor. then internship then community service year. at this stage you are a general practitioner. i think this is what you guys call a primary care physician.

then you study for a further 4 to 5 years to become a specialist in internal medicine. and it is this creature we call a physician.

shadowfax, maybe the use of the word only was not ideal. but then again an extra five years of study is not to be scoffed at.

here to do cardiology you'd have to do a further two years so by study time they are above physicians (south african definition).

we view all specialities as pretty much on a par, although i'm sure everyone secretly wishes they were general surgeons.

sindz said...

Maybe if I explain our training you'll understand.

We do 5 or 6 years of basic medical training. The first 2 years are theory and anatomy. The latter years are clinical. So we rotate through every single field of medicine.

At my alma mater we did everything. Internal medicine, surgery, obs and gynae, a stint in haematology, GIT, derms, psychiatry...everything. So by the time you're are ready to be a GP.

You serve your compulsory government years and then as explained before, you're expected to specialize.

So people like me, that have NO intention of specializing are frowned upon...even my dad has been bugging yes there is a prestige thing going on here in South Africa...actually in Southern Africa as a whole...

sindz said...

Bongi you used the word 'only' correctly. That is the prevailing attitude in our country.

"Oh so you're only a GP? I see..."

And NO the specialities are not viewed on par...LOL! It's a toss up between the surgeons and the specialist physicians!

Bongi said...

i actually must disagree with sindz. although there is pressure to specialise just after graduating (first 5 years or so) only about 10% of south african doctors actually do specialise.

Laz said...

Bongi, you are lucky! I have an American MDPhD student at my unit who believes that all African doctors are sub-optimal and only the Americans ca do any decent research (and he's not even "only a doctor" yet!)
Meanwhile, the "only a GP" thing seems to be fairly limited to medical circles (and medical families mayber). My non-medical friends treat me as if I'm the walking Harrison's: from where to get a breast reduction to diagnosing obscure autoimmune conditions in their kids. Sometimes I WISH they'd realise I'm only a GP!

Greg P said...

In general, I think doctors are like everyone else, only more so.

Anonymous said...

Regarding the meaning of "Primary Care Provider" in the US, the term describes the role of the doctor more than any specific qualification.

Certain medical insurance plans in the US expect one to declare one doctor as an initial contact point for all treatment. They provide you with a list of allowable primary care physicians, and you choose one. Then, if you believe that you need to see a dermatologist or other specialist, you must at least call this doctor and receive a referral. Obviously these rules are relaxed somewhat when dealing with emergency situations.

Doctors chosen to fill this role are often specialists in internal medicine or family medicine. They can also be general practitioners or gynecologists.

Anonymous said...

SA/Britain vs USA for dummies or physicians:
US premed = doesn't exist in SA (once you get chosen for medicine, you can only finish as a doctor i.e. No undergraduate + MD...we have 2 bachelors instead (takes 6 years), namely surgery and medicine.

US internship takes place in 1 field only i.e. It's effectively the preschool to your chosen specialist field. You can also intern in family medicine afterwhich you can be a GP or do a further 3/4 years to become a specialist GP (which is what family medicine). Should you choose a dedicated field to intern in i.e. Internal med or surgery, then you'll pretty much move onto residency in that field. In SA we do 2 years intership through every major facet of medicine, then we're GP's.

US residency is what we call registrarship. This means specializing.

what you call an internist we call a physician. What you call a fellow, we also do. Here you spcialize for 4 years, then subspecialize (as a fellow), whereas in the US it's all part of the parcel, like internship...i.e. You pretty much choose to become a cardiologist from the get go, whereas here it'll be the last thing we do.

what you call an attending (qualified hospital specialist in charge of a firm) we call a consultant.

Cardiology, infectious diseases, rheumatology, pulmonology, nephrology are all subspecializations of internal medicine, which in turn is a specialist field itself (what HOUSE MD is - diagnostics etc.) and to become a cardiologist in SA incl. 4 years registrar training in internal medicine to get a masters degree, thena further 2 years as a certified fellow. Add the 2 years for general medicial officer post and a compulsory year as community service officer, to the whole shebang to subspecialize in SA takes 15 to 17 years. Whereas to be a GP takes only 8.

That's what 'only' means - its almost a decades learning and experience difference. And amongst SA doctors if your a super (sub-) specialist you've achieved the all inclusive pinnacle, wheras is the US (and I speak from friends studying there), the route to cardiology (which isn't a subspecialization in most states) is stream lined i.e. You don't have to do internal medicine first, but rather rotate there for a while.

Q. So which is better?
A. Apples and pears - one fat flippin apple versus one super streamlined pear.

SeaSpray said...

They sound like terrific people. I am a firm believer in respecting people, being gracious and thank yous in whatever form.

For my doctors..that means a nice thank you letter and food.

Enjoyed the post and reading the differences in our cultures. Interesting.

Jabulani said...

Sea Spray: saddening isn't it that some people somehow think a "Thank you" is beneath them, e.g. in restaurants, the post office or, say, surgery.

My daughter had 2 operations early on this year. Following the first (major) operation, to thank the surgeon, I stitched him a whacky scrub cap. He (and the prof of his firm) was amazed that I'd take the time to stitch something especially for him as a thank you. They don't often get them, apparently!!

She had to have follow-up surgery and then a couple more clinic appointments. When he finally signed her off, we asked him if he'd like another cap and gave him a choice of fabrics. He said he'd love one, but didn't expect me to do so. When I said it was my way of saying an enormous thanks to him for repairing my childs' duff arm, he told me I didn't need to. So I responded "Well, I know I don't need to and you were only doing your job, but you still deserve a thank you and it probably doesn't happen often enough." He smiled somewhat enigmatically, which I guess is the English way of saying "Damn right it doesn't"!!! Then he said Thank you!

I've learned over the years, that something as small as a smile or a Thank you can turn someone's day around on a sixpence. It's THAT powerful and we just don't harness it enough.