Mike is a doctor from the UK who’s recently begun work at the MSF / Doctors Without Borders project in Irbid, Jordan. The clinics provides health care for Syrian refugees and vulnerable Jordanians, and Mike will be using his skills as a trainer and educator to support the medical staff at the project…
In the UK, a lot of my life has been linked to sitting in with doctors, seeing them consult, and supervising them. It is good to be doing the same in a rather different setting. So much is different, but it is relief to find that a common bit is seeing doctors who are clearly enjoying their consultations with their patients. There are periodic smiles and peels of laughter between medical questions and the occasional examination. Though I have some words of Arabic, I’m watching the process, the non-verbal cues, and the pattern rather than hoping that I’ll follow the discussion. Luckily, I recognise words which say when they are talking about the heart, and when it’s the head or pain elsewhere.
One of the challenges moving from one country to another is that the meaning of words is different. It took me a few days to realise the a ‘General Practitioner’ in Jordan is a person who has completed their training and registration posts, but has no specialist training. Those who have gone on to do Family medicine training rotations (normally 3 years) will call themselves 'Family Medicine doctors'. I’ve learnt not to describe myself as a GP, but to call myself a family medicine specialist to avoid confusion. This gets more complex when talking about the Royal College of General Practitioners (Which I still have work links with and which was involved in my recruitment process!)
The clinics that our doctors work in are are spaces loaned from a local charity and from the Ministry of Health, and whilst I’m used to GPs in UK complaining about lack of space and cramped conditions (with reasonable justification in my experience), the space challenges in both of our clinics in Irbid are enormous. The rooms are small and difficult shapes and the storage of the notes includes some in one consulting room as there is nowhere else for them. However, this does not seem to affect the patient’s desire to be there!
Our clinics will only enrol patients who have a non-communicable disease or 'NCD'. This is the official World Health Organisation term for conditions like cardiovascular disease (angina and strokes), diabetes, asthma, chronic obstructive airways disease (COPD), hypothyroidism - conditions that you can't 'catch' from someone else. We also include treatment for depression and anxiety for those who have an NCD. Those in British primary care might translate this as chronic disease management clinics.
Checking the appointment book. Photo: N'gadi Ikram
The patient journey through our MSF NCD clinic is different to the path I am familiar with. Those used to traditional primary care in UK might assume that on one appointment the patient is seen by the receptionist and then by either the GP or the nurse, and occasionally after this by the phlebotomist, a health care professional who specialises in taking blood.
Here, the patient will still start with registration, which is still through a paper based appointment book/ (Though one of the projects on the agenda whilst I’m here is supporting a move to a computer based appointment system). Then the nurse will see the patient, and this will mean that by the time the doctor (and some are GPs whilst most of them are Family Medicine doctors) sees them the pulse and blood pressure and other signs will all have been assessed. Then the GP consultation, though as yet with no computer, and writing prescriptions with carbon copies, and a similar system for lab requests too.
One of our challenges is that the doctor can do what they can for our chosen illnesses in a chronic disease primary care setting, but sometimes it is appropriate to see a specialist, and arranging this can be difficult. For the doctors who have often got to know their patients well having worked in the clinics for a year or more, the linked challenge is when problems are beyond the remit of the clinic e.g. if they get cancer and our clinic is not set up for this, but there may be little to suggest as an alternative.
I’ve sat in with several of our doctors, and much of the care that is recommended in international guidelines is given by them with the limited range of drugs that MSF provides free to our patients. One man needed to be seen by a specialist as the kidney function was dropping significantly and dialysis looked necessary in the near future. On this occasion things were easier as he was a Jordanian who has chosen to use the MSF service, and was able to get support from family to be seen in a local hospital. The programme has 30% of our patients coming from Jordan which is an expectation on all NGOs working in Jordan. All the patients who are enrolling who don’t come with Syrian refugee status are assessed for their vulnerability to ensure that we try to keep to our remit of helping those who have little access to health care.)
When problems are beyond the remit of the clinic, there is little to suggest as an alternative
After seeing the doctor all patients should go on to the health promoter who will review with them key messages that the doctor wants emphasised, including, in almost every case, reminding the patient about what drugs to take, when and how.
After seeing the GP, all patients should go on to the trained health promoter, who will discuss key messages that the doctor wants emphasised with them. This generally includes reminding the patient about what drugs to take, when and how.
Possibly the most obvious difference to consultations that I am used to is that the consulting room door is generally open through the consultation, and even if it is closed there are many interruptions - for example from someone delivering notes to the doctor's desk about patients to be seen, collecting patient notes, patients coming back in again to ask something else, to name a few examples. Or it might be a pharmacist to check a script, or a nurse with a worry about a consultation. There seems to be a never ending sequence of people coming in, and I know that I’d find it difficult to maintain concentration, but the doctors here seem to manage it!
The doctors here are all very knowledgeable about their patients
The consultations I’ve seen were more doctor-centred than I would hope to be offering in UK; time pressure is tight and the belief that giving the patient the “golden minute” in which the doctor listens but does not ask anything (which is advised in British Family Medicine) at the start of the consultation will pay off in the end is not evident in the consultation styles I’ve seen.
On the other hand, the doctors are all very knowledgeable about those they see as unless the doctor is away or ill, they will see the same doctor every time. The patients are only enrolled in the clinic if they already have one or more of the chosen Non Communicable Diseases and so are medically complex and likely to have many different problems, so they tend to need to be seen relatively regularly. There is a familiarity with their lives and problems which has become a lot less noticeable in UK practice, and is very admirable in any setting and especially useful with addressing the challenges these people face.
In the consultation room. Photo N'gadi Ikram.
I find myself with questions about what I can teach the doctors here. There is no sense in trying to move in one step to the model of care used in UK, especially as that model has its own faults and isn’t entirely applicable here. At this point I hope to largely listen to concerns, to observe and to provide a fresh pair of eyes on things to see if systems can be tweaked to support the team more, and to provide little nuggets of technique or knowledge which will may help in the immediate present. I need to find what the doctors themselves want and think before I can help to find solutions, so that we can work well together to adopt any changes and keep improving the service we provide as a team.
Top image shows a patient being seen by a nurse. Photo: N'gadi Ikram