Groote Schuur Hospital

As an elective student I was expected to function as a doctor and see patients both adult and paediatric that attended the outpatient clinics assist on the dermatology ward, clerk patients that came into the Emergency Department and accompany the registrars to do consults on other wards. The dermatology ward had thirty beds that were almost always full. Patients were treated by the ward registrar, intern and highly skilled nurses. Common admissions to the ward were Stevens Johnson Syndrome, Toxic Epidermylysis Necrosis (TEN), crusted scabies, eczema and psoriasis. The former two as a result of the anti-retroviral drug Neviripine and tuberculosis treatment Rifampcin. Team work was imperative to the effective running of the ward and patient education was pivotal to decreasing the frequency of admissions.

Dermatological emergencies were always managed at ward level with continuous supervision from nursing and medical staff. The mortality rate was low in comparison to the UK where these emergencies are always admitted to intensive care and have high mortality rates.

Outpatient clinics were busy starting at 9am and finishing at 3pm. By the end I developed good time management and prioritisation skills. My history taking and examination skills improved and I quickly learned that in this population group a comprehensive drug history was pertinent as many patients presented with drug induced skin disease.

In paediatric clinics I developed a good eye for recognising human flea bites and scabies from physical examination.

South Africa has nine official languages and many patients did not speak English as their first language and therefore I relied heavily upon my colleagues to communicate with them. We did not have access to interpreters as we do in Europe and I was in awe of how the doctors often spoke many languages and dialects. From this experience I have developed skills at maintaining a good rapport with patients when there is a communication barrier.

The team allowed me to carry out as many practical procedures as I wished under supervision although I often had to be assertive, seeking assistance with tasks beyond my abilities and skills.

I found that my work with the impoverished most satisfying; the patients were very happy and content and never complained about the poor hospital food- as they were delighted to have food or waiting times at clinics as they were so delighted and grateful to see a doctor. The patients often travelled a huge distance to receive hospital care, I recall one patient with Stevens Johnson Syndrome travelling four hours by train to get to the hospital for emergency treatment.

I developed great respect for the doctors and consultants who dedicate their lives and skills to the public hospital system in South Africa as the medications and materials available are often primitive and in some instances not available at all. Clinics that we attended in the townships often had very simple medications where the only equipment were a stethoscope, a sphygommeter and small couches, there were no curtains and therefore patient privacy and confidentiality didn’t exist. I was astonished at the willingness of the patients to expose all parts of their anatomy no matter how many people were in the room.

What did I learn?

I have gained a substantial amount of knowledge in the area of infectious diseases and their cutaneous manifestations through the adverse effect of anti-retroviral agents or as a result of the disease process itself.

The majority of our patients lived in the slums, where their homes were temporary structures made out of paper, wood and iron sheets on waste ground.

I have further insight into population congestion and demographics and the influence of social difficulties such as prostitution, rape and incest on the acquisition and spread of disease.

I further understand the negative impact that food shortage has on skin disease and can recall many inpatients whose skin conditions improved during their inpatient stay due to proper nutrition for example the patients with psoriasis who were taking metotrexate improved significantly with a more stable diet and folic acid supplementation. Many of the children had kwashiorkor’s disease with protracted inpatient admissions.

I was given the opportunity to attend rural clinics in Hout Bay with the dermatology intern and undertake a dermatology field trip to a town Botrivier. On these occasions students were sent with a doctor to diagnose and treat skin conditions. These clinics had basic resources often the most potent steroid was hydrocortisone. The patients had huge difficulty accessing healthcare and if they could not afford the train ticket to Cape Town then they were denied access to hospital facilities. I was frustrated and upset by this as so often we diagnosed serious conditions but patients could not be treated.

How has my elective changed my practice as a professional and person?

I feel that my elective was akin to an emotional roller coaster, as I frequently reflected upon the disparity that existed between rich and poor. The poor lived in abject poverty and squalor while the wealthy lived in grandeur.

Many hours of joy and fun were offset by sadness as I was seeing so much suffering. Many people had HIV, where there continues to be serious stigma and myth, and a lack of education amongst the adult generations. Early this century the health authorities tried to combat this stigma and change its name to retroviral disease (RVD) but to no avail. Many people in these communities are illiterate and may not understand what HIV is and therefore explaining how to prevent its spread has little impact. Also the nature of human beings is such that knowing the risks and consequences of behaving in a certain way does not actually change the behaviour.

I saw the degradation of countless women and children particularly in the coloured communities where they were subject to sexual violence. It was not uncommon to see a child with genital warts due to immunosuppressant with co-existing gonorrhoea. Child abuse was rife and widely accepted within these communities. It is still widely believed and practised that if a man slept with a virgin he would be cured of HIV. I felt that when dealing with these young children and their families that I was often going through the motions, taking an air of clinical detachment trying not to get too involved with the enormity of what was after happening within the family and try to deal with the task at hand. I further understand the role of the doctor and team in the investigation of such child abuse cases.

Theory and Practice

Initially I was shocked by the lack of infection control measures in place in hospitals/ clinics especially when examining patients with HIV/AID’s, hand washing and the use of disposable gloves were virtually non-existent. Doctors wore casual clothes to work and I recall one doctor stating that our patients have much more serious conditions than what lives on our clothes.

During my elective I was thought how to carry out cryotherapy and undertake skin biopsies. I can now use my clinical judgement to make appropriate referrals to a dermatologist for these procedures. In the paediatric clinics I took many skin samples and I can identify a scabies mite and its eggs under a microscope. I also removed skin tags and often drained abscesses. I also had ample opportunities to practice my suturing skills.

I have learned to think on my feet and become more proficient at identifying skin conditions that are emergencies and require imminent admission to those that can be treated on a daily basis as an outpatient. However, I understand that I am a novice at the identification of many skin diseases but recognise that this is a postgraduate speciality where repeated exposure and pattern recognition are important.

I have been exposed to many infectious diseases especially HIV and have become more accustomed with the drug reactions and the cutaneous manifestations of systemic illnesses. Stevens Johnson was alluded to as a rare condition throughout my undergraduate training and now I have seen hundred of real life scenarios.

Many of the patients were socially deprived, with low literacy levels and therefore compliance with treatment regimes was poor. I realise the importance of providing information in basic simple terms and not giving information in a written format to patients who do not read.

Conclusion.

South Africa is a country where tremendous wealth and palpable poverty co-exist. As a country, it is at a crossroads where developing and evolving countries often find themselves. Since the fall of apartheid, the country is still in the throes of immense change.

I feel very privileged to have been able to undertake my elective in Cape Town. It was an amazing experience in both a cultural and clinical context. I found the dedication and work of the doctors within a healthcare system that was stretched in terms of resources and staff most inspiring. They were good and willing teachers and showed strong team work from which they helped each other to learn. I have seen dermopathology that I may never again see in the western world. I pledge to take the experiences and kindness of my patients forth in my future medical career and therefore I feel that I must conclude with a word one of my patients thought me.

Abutu: it means if I have you have, in essence you and I are connected through our humanity, that we all share a common morality.

Immense amount of responsibilites and practical work e.g. clearing C-spines, airways, suturing, chest drain insertion, CVP line under supervision. Not always supervised but good opportunities to brush up practical skills.

The staff at the hospital were very friendly and keen to teach. It was very easy to meet CapeTown students. Cape Town is a perfect setting for the elective, with some eye-opening, educational opportunities within the hospital, and outside a fantastic city.

Everyone was very nice and approachable. They are used to elective students and were more than happy to let us join teaching rounds with local med students. Very varied and interesting pathology.

I had massive responsibility to look after many of the patients that came in multiply injured. There were very few medical staff so I had many of the responsibilites of a foundation year doctor in the UK. Large responsibities to see and formulate management plans for the patients. We really felt as if we were needed and useful to the unit and we actually contributed something. We were thanked for our presence there in helping to take some of the strain of the doctorrs in the unit. Many procedures were offered such as inserting chest drains, cannnulations, suturing. Much experience and working with ATLS with helping in resus situations.

Very good. Great experience. I worked as an intern and would definitely recommend this elective.