Medical Care in Bhutan

Today's blog is going to consist largely of "medical shop talk", so let this serve as forewarning to those of you wishing for more of the travelogue (I should have more pictures following this weekend's trip to the Haa valley). 

Medical care in Bhutan is interesting in that many of the pieces are here,  The doctors and nurses are well trained, and though we lack some equipment and medications, that is not a major problem (work arounds can be found).  Just as in the United States, it is the organization of care (the systems and processes) which is lacking.  If one looks at the major advances in medical care in the U.S. over the past 10 years, I would submit that many of them involve the implementation of systems rather than new technologies (for example, "Central Line Bundles" and "Ventilator Bundles" which arouse out of the "100,000 Lives" campaign).

The first difficulty one encounters in Bhutan is the medical record.  Patients carry there own records,  They are not available from a hospital record room.  Some patients come in with the records beautifully organized in a folder.  However, often, a pile of papers is pulled or dumped from a bag.

Within the record, the only typed report will be laboratory results or perhaps records from a referral to India.  Pathology reports and radiology reports are generally hand written (CT reports are typed).  There is no order section.  Progress notes are the day's orders (You simply write the orders in the chart).  It is next to impossible to determine what orders are active.  There is no medication list and no history and physical as we would define it in the U.S.  The most challenging aspect is trying to determine the patient's story.  There is often no place in the chart to go to find the patient's medical or for that matter personal story (those who know me well know how much I appreciate patient's stories).

There are no scheduled clinic appointments.  Patients simply line up with their charts waiting to be seen.  We try to see all who are waiting if possible.  Yesterday I did 10 consultations in about 4 hours.  I've learned real quickly not to be hung up on American documentation requirements.  It is next to impossible to determine all of a patient's history, and medication lists are even more difficult. Family history is easy, as none of their relative see doctors.  All consultations are hand written.

As you can see, I have forced myself to learn not to write more than one page because of time limitations.  After writing the consultation, I give it to the patient who adds it to their chart and walks away with it.

We have no exam room on the oncology ward.  All the beds/chairs are in one room with no privacy curtains.  We have adapted the nurse's break room into an exam room.  Patients are escorted in.  They hand me their record, I review them, ask them a few questions, and then try to perform a limited exam.  We have no exam table.  I attempt to examine patients in a chair.  Their is little privacy, though that seems not to be expected.  If I need to see their x-rays, we send one of their family members (who always accompany them) to radiology to pick up the films and bring them back to us.  I write my orders at the end of my consultation note, though, their are forms to fill out for laboratory studies or x-rays.

Leaving the clinic is difficult.  All day there is a crowd of people outside the door holding their charts.  If I walk out they all come up to me offering me their charts.  Apparently the word is out that their is an American cancer specialist here and they all want my opinion.  They not infrequently expect that I have some special magic and can pull a rabbit out of a hat.  This has led to some disappointment when I have had to explain that I do not have a special treatment for them and that the care they have received has been appropriate.

We are attempting to create a system for ordering chemotherapy.   HVO (Health Volunteers Overseas, for whom I am working) authorized me to by a printer for the clinic, which I have done.  Annette, the oncology nurse practitioner working with me, is creating order sets for each commonly used chemotherapy regimen which we are attempting to get the nurses to use.  Annette and I both complete the order set, verify the dosages, and sign it.  A copy is then sent to the pharmacy.  Previously the orders were give verbally, the nurses calculating the dosages, and then copying them into three different places, including a book which was carried to the pharmacy.  We are creating a computerized library of the order sets, with the hope that this system will live on following our departure.  We also plan to add a flow sheet to the records the patients carry with them (a big problem is determine how many courses of chemotherapy the patient has already received and the date they are due for their next therapy).

The inpatient units are open wards with 6 beds per room and no curtains.  The sisters (nurses) are extremely competent and extremely helpful.  They are recognizable by their white uniforms and black sweaters or jackets.

They accompany us on rounds, and it is a true team approach to caring for the patients.  They work well under difficult circumstances.  I cannot say enough good things about them.

Finally, we do face some unique social problems (There is no such thing as a care manager here).  I consulted on a "Highlander".  She lives in a village in the mountains at about 20,000 feet altitude.  She had undergone a D2 resection for gastric cancer (the surgical oncologist I work with is skilled).  I was asked if she should receive adjuvant chemotherapy.  As I learned more about the patient, I found that to come to the hospital she had to walk five days down from her village to another village where she could get transportation to Thimphu.  If I gave her chemotherapy she would spend 10 days of every 21 day cycle traveling.  If she had complications from therapy she would have little access to medical care.  When we weighed the small but real benefit of therapy against the risks and logistical difficulties, we determined that therapy was not realistic nor necessarily in her best interests.  She did not seem displeased with the decision.