Cambodia: Clinic culture-shift
Theresa is working in an MSF hepatitis C project in Cambodia, where she's finding some things work a little differently than they do at home...
Being a clinic doctor in Cambodia is nothing like being a clinic doctor in the United States. This is obvious every time the patient sitting across from me starts speaking Khmer, but there are a bunch of other adjustments I am learning to make as I settle into clinic life here.
First, Cambodians are early-morning people. Although we only have four consultation rooms, the waiting area is full to bursting at 7:30 am when the clinic opens. Even when the staff advise the patients to arrive in the afternoon, people still prefer to get here before the doors open. This creates a hectic pace at the start of the day. 
A photo shows the big pile of medical files and the patients waiting for appointments
The waiting room at 7:20 am.  Photo: Theresa Chan / MSF
Second, interruptions to the patient encounter with a doctor are commonplace and expected. Several times during each consultation, the door to my exam room will slide open and one of the following will occur:
  1.  Another patient will return to pick up her file to carry to the laboratory.
  2.  A pharmacist will remind me to write the expected duration of treatment on the prescription form.
  3.  Another doctor will have a question for me about the co-management of a chronic illness during direct-acting anti-viral (DAA) treatment for hepatitis C.
  4. Yet another patient will return needing a written prescription for one of the anti-hypertensives which is not permitted during DAA treatment.
  5. A registration clerk will announce the arrival of an unscheduled patient who has been urgently triaged from our screening site for consultation today.
  6. Yet a third patient will return with a note from the pharmacist, asking me to adjust the number of DAA pills to be dispensed, despite my best attempt to calculate the correct number.
  7. A clinic manager will arrive, looking for the medical interpreter.
  8.  A member of the coordination staff of the project will peek in, just wondering how things are going today.
  9. Yet a fourth patient will return holding a printout of ultrasound images and will need to be told to wait outside for a minute.
  10.  A consultant from the nearby Gastrointestinal Disease Ward will wander through, looking for our Medical Activity Manager.

It's like holding clinic in your living room on a Sunday afternoon, when your whole family and a bunch of your friends are trying to watch television, make dinner, and do the laundry at the same time. There's a feeling of people getting in each other's way, of confusion of purpose, of good-natured crowding. To an American doctor who is used to having the closed door to an exam room respected, this takes some getting used to.
What is most remarkable about the hepatitis C clinic is how tolerant and good-humored the patients are about waiting all morning, and sometimes all day, to be seen. They doze on the benches in the waiting area, or they chat with their neighbors in line, or they sit outside of the consultation rooms, diligently reading their files--which is something else you never see in the United States, especially now that American medical records are largely electronic and don't need to be hand-carried into the exam room to give to the doctor. 
What you never hear in our waiting room are raised voices or bad-tempered complaining, which are all too common in the United States when wait times are long or when people are feeling desperate about their medical care. There is plenty of desperation among our hepatitis C clinic patients, but no complaints, only gratitude. When I ask them a routine question about feeling sad or anxious, many of them say: "Before I was on treatment, I worried all the time about hepatitis. Now I have nothing to worry about."  
(And yet I am still worried about what the next interruption into my exam room will be!)