Quality of patients

[Guest arjuna83]

Hi,

 

This topic might antagonize some (or probably all! heh heh) you Canadian medical students out there, but I just wanted see what you all think...

The general belief is that Medical education is of a much higher calibre in developed countries than in developing ones. I don't have any doubts about this. However, can we say the same for the diversity of patients that medical students get to experience in developed countries? before coming to Canada, I spent the first 19 years of my life in a 3rd world country. In these countries, there are a limited number of good hospitals that are all concentrated in the major cities, and a lot of people. Most of these people, when they get sick, end up coming to the few good hospitals. This in turn leads to a huge number of patients with a multitude of cases in each hospital. This is certainly not a good thing, but medical students of these countries get the opportunity to see any and every condition they study about.

But in developed countries, there are so many good hospitals spread out throughout the country and much fewer patients that the number of different cases you'd get to see in each hospital is a lot less. I can remember, when I was in Sri Lanka I attended a seminar in which an American doctor spoke. He said that within the few days he spent at one Sri Lankan hospital, he saw more cases than the cases he saw for 10 years he was practicing in the States. Quite intriguing.

 

What do you guys think?

[Guest Ian Wong]

I guess the question you need to ask yourself is: what makes a good doctor? Is it someone who has seen the full spectrum of pathology throughout human civilization, or is it good enough to have seen the spectrum of pathology that you are likely to encounter?

 

You're right. In Canada, you are much less likely to see a patient with a 50 pound tumour in their abdomen. You probably aren't going to see many cases of endemic goiter (because we use iodinated salt), nor many cases of pertussis(because of widespread vaccinations), nor many parasitic infections or malaria. On the other hand, in North America, you will see a lot of cancer, heart disease, diabetes, neurological disease, trauma, and other chronic degenerative diseases that you wouldn't necessary encounter once you get outside of our long-living populations in the first-world.

 

There's no doubt that living in a first-world country will limit the range and extent of pathology that you will encounter as a physician, but if your intent is to live and work within that region, perhaps it's best that you specialize within that range itself. I wouldn't expect a physician from a third world country to be intimately familiar with the latest guidelines for the screening of colon cancer, in the same vein that I hope they wouldn't expect me to know off-hand the best treatment for a roundworm infection of the GI tract.

 

Ian

[Guest UWOMED2005]

Yeah, I'm hoping to do an 8 week elective in rural South Africa during my 4th year. My reasoning is (other than the fact my grandfather was born there, I'd like to see some lions/giraffes/elephants, and I'd like to surf J-bay) that you'll see some developing world cases (and help out as an extra hand) at a hospital staffed by developed world docs.

[Guest noncestvrai]

UWOMED2005,

 

I don't need to remind you of the prevalence of HIV in Africa among other diseases. I had a friend, now in med school in Quebec city, who went to SA for vacation and was the withness of a horrible car accident, he helped the wounded, but used gloves. Suffice to say that you should be carefull and aware of your safety first.

 

Good luck though, I'm sure you will discover and learn a lot.

 

noncestvrai

[Guest Kirsteen]

Hi there,

 

On the above note, we recently received some results of a survey that we conducted among ~50 surgeons in Africa. The mean estimate of HIV prevalence among their patients was 40% and fear of contracting HIV was among one of their major sources of job stress. Many have no post-exposure prophylaxis available to them. Mind you, these surgeons were not located in S. Africa; instead, most were located in E. Africa, e.g., Zambia, Uganda, Mozambique, Malawi, etc.

 

Cheers,

Kirsteen

[Guest arjuna83]

I don't think it's wise to be limited to knowledge of diseases within your region. Canada, being one of the most ethnically diverse countries in the world, and with the speed in which people could travel from one country to the next, it's highly likely that someone who was in a malaria endemic region 12 hours ago contracts the disease and ends up 12 hours later in Toronto.

[Guest strider2004]

Don't forget that this depends on the kind of physician you'd like to be. If you want to be an infectious disease specialist, then perhaps it's best if you didn't limit your training to Canada. However, if you want to work as a cardiac surgeon, I doubt you'd find more bypass graft cases than in N America.

 

Everyone here is assuming that that variety only comes in the form of infection. You mustn't forget trauma, aging, congenital diseases (in many countries you won't see adult congenital diseases because the patients died as children), cancers, technology.

 

A person who spent 12 months in rural Africa might not know how to handle the farmer who ran into a fence with his snowmobile or the boy who fell into an icy lake.

[Guest UWOMED2005]

Noncestvrai -

 

You can't even imagine how right you are.

 

I got an e-mail from the staff I'm going to be working with - they said the official figures for HIV prevalence in that region of South Africa. . . but when they do (unofficial) random testing of patients they're now getting figures hovering around SEVENTY FIVE PERCENT (75%)!!!!! And I thought it was ridiculous a couple of years back when I heard 20-40% infection rates were being reported.

 

This is just scary. At current the rate the prevalence of HIV is increasing, and considering HIV positive patients without retroviral/protease inhibitor therapy live on average 5-10yrs max, by the time we develop a worldwide AIDS strategy to deal with HIV in Africa (and Asia and Eastern Europe where the incidence is skyrocketing) practically the only people left will be those naturally selected to be immune to HIV and HIV infected orphans.

 

All I can say about my personal feelings towards going knowing that:

 

a) Of course I'm going to use universal precautions. I'd use them if I thought my patient had a cold (or even if they were completely healthy).

 

The risk of transmission from patient to health care worker is very, very low

 

c) If we all avoided patients that were sick because we were worried about getting sick ourselves, who the heck would be left to treat the sick?

 

arjuna83 - the issue is not that malaria cases don't occur in Toronto (or London for that matter) but rather the chance of seeing such a rare thing is unlikely in clerkship. But you are right - we do see tropical diseases like Malaria now in Canada.

[Guest therealcrackers]

I saw one case that shows how right everyone is on this topic.

 

A little boy, 5 years old, family arrived in London from Guinea about 3 weeks previously, but they are actually Liberian refugees; one of the children in the family was a child soldier a few years back.

 

Risk of him being HIV+; about 20% --- I don't know if they got the consent for the treatment because he was going to be treated as an outpatient (inpatient for a refugee with no insurance being VERY EXPENSIVE).

 

His diagnosis in the ER, given his fever, his age, and his background: malaria.

 

And it's true, he had malaria, but at a level of about 0.1% of his red cells infected and stable at that level (he's practically immune from his endemic exposure). But why he had the fever and the problems was that he'd picked up a run-of-the-mill virus around here, RSV most likely, and that was going to be the bigger problem for him...

 

Fortunately, the ID consultant had done some training in the third world, and saw what everyone here has said; the combinations of first-world and third-world disease and medical practice are what we all have to remember to take into account, based on our experience and the setting in which we choose to practice.