Mike is in Jordan, where he's part of MSF / Doctors Without Borders team who offer health care to the thousands of Syrian refugees and vulnerable Jordanians who live in and around Irbid. With long experience of training family medicine doctors in the UK, Mike is managing several teams providing vital care...
So, what did you actually do today?
In some of the e-mails I’ve had from friends, this has been a question I’ve been asked (though in more polite terms) quite often. The reality is that no two days are the same, and that often work carries over from one day to the next. So, though I’ve been working on all of the projects I’m going to describe, it’d be wrong to suggest that any of them have been finished in one day.
Mike in the Irbid office. Photo: MSF.
Like all work, how much gets done depends on how many meetings there are to distract you from doing the job (!?). One of the first words my Arabic teacher taught me was Ijtima’ (meeting), saying that as I was joining MSF I needed to know this word from the start!
What I did today...
MSF has over the last months been expanding the work it does with the patients who have chronic health issues but also have depression. In Jordan drugs used for psychiatric disorders are managed separately from other drugs and have to be stored in a secure place, and only prescribed by a specially trained person etc. (UK clinicians might want to think of them as controlled drugs in some ways). So, I’ve been adapting a protocol written for an MSF project in Iraq to form a standard operating process (MSF likes these) on how we will manage psychiatric issues and patients. We don’t do things in quite the same way and we have set up a screening programme for our patients with PHQ9 questionnaires so lots lot of it needed to be changed. (PHQ9 is a questionnaire to screen for depression that is commonly used in primary care in the UK.)
For many years as a UK clinician I have been testing ACRs (albumin : creatinine ratios) for patients where we are concerned that there could be a deterioration of kidney function due to diabetes or hypertension.
The idea behind testing ACRs is that measuring the ratio of the albumin (which should not be excreted and is the sign of damage) to the creatinine (which should show how the kidney is functioning overall) is more accurate as a measure of kidney damage that just measuring a random sample’s UAC (urinary albumin concentration). Testing only the UAC is cheaper: 2/3 of the cost on our local figures. So, I’ve been reviewing the evidence provided by MSF’s central lab adviser and advice from a friendly nephrologist (thanks Charlie!). This shows that we should change the test and only do the UAC as it is just as accurate (despite international advice). This also means changing the form… and redesigning that (both of these are done) … and will mean telling logistics to print the new forms once this decision is reviewed by our medical coordinator for Jordan etc.
I did an evaluation (UK doctors might call this an appraisal) of one of the clinic doctors at the end of last week and today I finished writing it up and reviewed what I’d written, clarified it and shared it with him before formally getting a signature to confirm it as accurate and formatively useful.
The project is celebrating three years of helping Syrian refugees and vulnerable Jordanians later this week and despite my relatively recent arrival I’m part of the group organising the celebrations. There have been discussions about what to do, how to arrange this, what prizes will be most valued by participants etc. Not sure that I’ve brought much technical knowledge to this but it has been a good way to work with our project coordinator and our (even newer than me) logistics lead.
The project has got approval for a nurse to manage the referrals we make to external agencies. I‘ve not experienced this yet but the pattern seems to be that some charities will pay for several days of, for example, cardiology time from a specialist and their team in Amman and suddenly the team here needs to get all the right people with the necessary documents to the right place and back (often a day later) for them to have their cardiac catheter or ophthalmic screening for diabetes or… This is a logistics nightmare which we hope to employ a colleague to manage, and so I’ve been writing a job description for this person with the help of our nurse supervisor. (With of course, all sorts of quality improvement inputs during the times that there is no referral drive to manage!)
A few more things...
All MSF projects try to have several ways to assess the quality of the care they provide. This can be done in a variety of ways but given that the international team generally speak poor Arabic it is important I think to go beyond sitting and trying to assess consultations! I’ve involved myself in several plans around how to measure quality to help the organisation know how it is doing, but also to feed back to the doctors or nurses factual information about their performance in a useful form so that they can improve and develop.
So, part of today was spent writing an exit interview format, or what doctors from the UK’s National Health Service might call a ‘patient satisfaction tool’. This was drafted today (again with my nurse supervisor colleague) along with an explanation of why this approach is being suggested. As there are few non-communicable diseases projects in MSF and the balance of questions needs to suit the project, the tool will doubtless need some tweaking, but we hope to have a final process and tool finalised in time to start using this by January 18.
I chatted for a while with my logistics colleague about how the process for reviewing drugs which might expire unused or which we might run out of was meant to work, and whether it was working in this way at the moment. No conclusions today, but useful to see how we approach the challenge and to share thoughts on who should be leading on the data preparation for these meetings.
I had a little time with the home-visiting team that I manage as today the doctor in the team was late due to a rescheduled lecture for his master’s course, and as I’d emailed the physio in the team a couple of days earlier about whether we had the equipment to adjust walking sticks so that sticks are as useful as possible. We had a lively discussion about the length a stick should be, and I think raised awareness of the issue with the nurses in the team which should help those the physio doesn’t see but who have a stick.
Oh and I didn’t get to see any of the clinic teams today; somehow there did not seem to be time?