Ethiopia

England

Comments

Patient staggers in obviously distressed and in pain. I ask: “How are you?”

Patient shakes my hand and/or bows to me and tells me several times over and in several ways that they are fine and very well, praise God, and asks how I am?

Patient immediately tells me how awful they feel and may possibly burst into tears (this tends to be a bit sex-dependent though…)

In England if the patient is coming to tell me about their cough I will often hear them practicing their cough on the way down the corridor…

History

It is quite possible they will not tell me what’s wrong with them this time. That may happen next time they see me. There will be minimal eye contact whatever. I’ll get a history of something, but there may be a lot of surprise at the number of questions I ask.

I’ve got most of the history by  now – they’ve already started. Eye contact may be minimal if they want to communicate how bad they feel. There may be a link between the amount I ask and the score I get for being a caring doctor on the post-consultation quality questionnaire.

Much of the “care” my Ethiopian patients have experienced before will have been very brief, with no explanation or diagnosis and always some treatment, often by injection. They have come to expect that if they bring me a problem there will always be a solution.

Age – “how old are you?”

Very few Ethiopian patients are ever asked this and very few know when they were born. Some will work it out based on the age they thought they might be when they had their first child. Some just guess. When they see me next time they may be a few years older or younger. My oldest patient told me she was 50. I don’t think so!

No need to ask – it’s on the top right hand corner of the screen of course.

I’m using paper notes here for now. I’m going to have to do some inspired guess work around age when I come to computerise the records.

Timescales

“Fifteen days” probably. Although now I understand some Amharic I can hear the translator firing direct questions – “1 month? 3 months? 1 year? 15 days?...”

I’ll get accurate timings usually, sometimes from an app on their iPhone dug out from under the sheaf of paper containing all the Internet research they have done.

The Ethiopian culture is a “now”, “survival” culture. Timescales are less relevant and therefore often not remembered. There is a problem now.

Examination

Although they may have rarely been examined by a doctor before, there is little coyness here. Sometimes they will begin taking off the wrong bit of clothing. Sometimes they will expose themselves somewhat alarmingly. They won’t put their feet on the couch with shoes on though.

This is expected but can be accompanied by a lot of embarrassment. On occasion a request to examine their chest will result in pulling apart the material between 2 buttons leaving a 2 inch diamond of chest exposed, barely bigger than the stethoscope head.

My oldest patient is typical of many older Ethiopians who have a great fear of the adverse health effects of cold air. Last time I saw her she had six layers of clothing on which made a chest examination remarkably difficult. Bear in mind we are 9 degrees north of the equator in the tropics!

Assessment

The disappointment is palpable if I don’t immediately say what’s wrong. Even though they will sometimes feel they know what’s wrong, they’ll not tell me that. Not this time at least.

Explain findings. Discuss. Answer questions. What exactly did Prof Google say was wrong? Explain why a viral illness is more likely than pulmonary aspergillosis in the UK.

Ethiopian health workers will rarely tell a patient what’s wrong, what the treatment does or what the investigations are intended to achieve. It’s a surprise when I want to do all these things.

Investigations

These are gladly received, often done the same day and the patient will be back later with the results. The quality is sometimes questionable and sometimes they go to different facilities from the one I recommend as it’s cheaper or nearer home. Travelling is really difficult usually.

Reasons for investigations will be carefully explained, why they are being done, where they will be done and how long the results will take. A result will almost never be available the same day and often not for several weeks. An Ethiopian would have no understanding of this at all.

Because investigations are done at the drop of a hat by the local Addis clinics (one day of diarrhoea – stool test; 1 day of abdominal pain – ultrasound etc) expectations of both them being done and of the helpfulness of the results are hopelessly misplaced. Faith in the results is massive and usually unrealistic.

Treatment

Drugs may or may not be available. I issue prescriptions but most pharmacists will sell most things without one. They will dispense the medication and give the prescription back to the patient. They may or may not get what I prescribed, and may or may not get the right quantity. The patient may not take the prescription to the pharmacist at all if they think I missed the point of the consultation even though they never told me why they came.

If I recommend treatment there will be a discussion of side effects, interactions, long term effects, why this is better than homeopathy or Chinese herbal medicine. If I don’t recommend treatment there will be a discussion of viruses, bacteria, local prescribing policies, side effects of antibiotics, and the fact that I am not refusing to prescribe just because it’s expensive.

The Ethiopian expectation is often that if there is a problem there must be a solution, and certainly a medicine. After many discussions I am detecting that there is no understanding at all what a viral illness is.  That could explain why the Amharic word for “virus” is “virus”. In fact the word isn’t even in my Amharic dictionary at all.

The end…

Sometimes I will be thanked, God will be praised, blessings will be called down upon me, and the patient may bow and leave saying “ishi” (a sort of general “OK” word) quite a lot. Although sometimes one “ishi” will do and they will leave with a rather difficult to read blank expression, leaving me completely in the dark as to how successful or otherwise I may have been.

The consultation may end with the patient completing a customer satisfaction survey form to contribute to the practice's "balanced score card" and for me to put in my appraisal folder ready for revalidation.