Saturday, April 20, 2013

Day Eleven: SEMDSA day two and goodbye

Today we had to say goodbye to our wonderful hosts at Bara, Prof Shires and Kershlin, as well as all the other physicians, diabetes educators, and nurses who ensured we had a wonderful and educational experience at Bara Hospital. We thoroughly enjoyed our two weeks, learning about the South African medical system, discussing endocrine cases with endocrinologists, general medicine physicians, surgeons, and radiologists, and meeting patients and hearing about their experiences of medical care. We saw many interesting cases, some advanced endocrine pathology, and learned much from our Bara colleagues. 

Additionally, everyone was incredibly welcoming and ensured we were able to see the sights (and taste the delicious food!) of Joburg. We are really looking forward to hosting Prof Shires and Kershlin in Pennsylvania. 

The Endo Ambassadors!! 

I hope you enjoyed the blog and I look forward to meeting you and hearing your thoughts and feedback at ENDO 2013. See you in San Francisco!

Friday, April 19, 2013

Days Ten: SEMDSA day one

We ended our visit to Bara with the Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA) conference.

Thank you to the ENDO society for providing the lovely ties. 

Day One

Madame Bongi Ngema-Zuma, the wife of South African President Jacob Zuma, gave the opening address. She discussed the impact of diabetes on her family and her many efforts to increase diabetes awareness in South Africa. In 2010 she started the Bongi Ngema-Zuma Foundation, which seeks to drive the empowerment of women and children, rural development, education and health primarily about diabetes and its complications.

Madame Zuma speaking about her work to increase diabetes awareness.

Dr, Ian Campbell, Ilona, Dr. Mandel, Madame Zuma, Prof Shires, and Kerslin at SEMDSA.

The day was full of fascinating plenary sessions and abstract presentations, primarily on interventions for diabetes and obesity and the evaluation of metabolic complications. Dr. Peter Trainer gave a particularly interesting talk "Understanding the numbers" about the performance of different growth hormone assays, highlighting the importance of being thoughtful when interpreting our biochemical testing. Dr. Mandel led an afternoon Meet the Professor Session on "Molecular testing for thyroid nodules" and a talk on "Screening for thyroid disease in pregnancy."

Mid conference coffee break, fulfilling the American stereotype. 

Dr. Mandel giving her talk on "Screening for thyroid disease in pregnancy" 

Wandering around after the conference and catching a game of bowls at the Wanderer's Club

Thursday, April 18, 2013

Day Nine: Endo 101

Today we attended Endo 101, a prequel session to the SEMDSA (Society for Endocrinology, Metabolism, and Diabetes in South Africa) meeting, intended for general practitioners. The sessions covered the key topics in endocrinology that primary care physicians need to know. As there are only 40 trained endocrinologists in SA, the majority of patients with endocrine issues will be taken care of by general practitioners or nurses (in the public system, as was the case at the Moroka clinic). The morning talks were on basic diabetes management, PCOS, and bariatric surgery. In the afternoon, there were sessions on subclinical thyroid disease, primary hyperparathyroidism, osteoporosis, ED/testosterone replacement, and lipids.

The last lecture of the meeting was a fascinating talk by a linguist, explaining the ways that intonation, grammatical structure, and the increasing use of slang (among others) in the African languages can all contribute to poor understanding between patients and physicians (who speak primarily English). After she reviewed that certain medical concepts (that we assume everyone understands) did not exist in some of the African languages, I definitely understood better why I had noticed that sometimes a simple question from a physician would require a long translation and at other times several physician questions could be translated into a simple phrase.

Some of the more interesting translations provide insights into people’s conceptualization of disease “I am held/captured by the heart” (meaning I have heart disease), “I have a head” (meaning I have a headache – as the only time I am aware I have a head is when it hurts), she is a member of iPAC  -or any 3 letter combination (she has HIV, as given the stigma HIV cannot be said in name, but can be alluded to in a way that everyone understands).  

A much better excuse than the dog ate my homework. 

Wednesday, April 17, 2013

Day Eight: Moroka clinic, endo rounds, and QI talk

In the morning, Dr. Mandel and I met Dr. Pauly at the Moroka clinic, one of the primary care centers in Soweto. Driving through Soweto, we again saw the diversity in socioeconomic status. We drove past bond houses (purchased from developers), RDP houses (purchased through the government, and shanties (costing about 350 Rand pre-assembled or self-assembled by the owners of the shanty).  

A park close to the Moroka clinic
latrines in front of shanty houses. 

The Moroka clinic is staffed by primary care nurses, who alternate between providing acute and chronic care. Patients with all medical conditions are seen at the clinic. In addition to care of chronic health care conditions such as hypertension and diabetes, children receive vaccinations, and pre-natal and ante-natal care are provided. There is also a TB DOTS center and a separate building for HIV/AIDS patients (because patients would not come to the clinics, as they did not want to be seen by their neighbors). Two days a week there are diabetic clinics, but as diabetes is so prevalent, diabetic patients are seen at the clinic every day. The physicians here estimate that patients with diabetes present about eight years after the onset of diabetes, so complications at the time of diagnosis are not uncommon. 

Reviewing a patient's blood pressure history with one of the nurses.
Lafundo counsels a patient about how to manage exercise (football)-induced hypoglycemia.

Dr. Pauly tries to ensure that younger patients come to Bara, as patients are more likely to have an HbA1C drawn, to receive an evaluation for diabetic complications, and receive more aggressive glycemic control and control of other risk factors. However, cost can be prohibitive (the cost of transport might be 8 Rand each way and the cost of the medical visit is 40 Rand -> this is about $6 or $7). One of our patients was a 29 year old with an eight-year history of diabetes, diagnosed during pregnancy, who presented with a BP of 180s/110s. We attempted to encourage her to come to the Bara clinic (she had previously been seen at Dr. Huddle’s pregnancy clinic and her memory of Dr. Huddle’s clinical care elicited the only smile she gave during the visit), but she initially told us that she would not come because she could not afford it. She was an orphan, did not have a job and was caring for her son and two younger siblings (they all live together in a shanty house), intermittently receiving money from an older sister. This family dynamic is not uncommon here. In comparison to the costs of medical care at Bara, the primary care clinics are free; however, there are mechanisms at Bara where the cost can be waived.

We then headed back to Bara for endocrine rounds. 

Impromptu barbor shop

We rounded with the endocrine team on several patients: a patient with anaplastic thyroid cancer (whom we had seen previously in gen endo clinic last thursday and on post-intake rounds last friday), a patient with pre-existing NICM and Graves' disease, a patient with ARV-associated gynecomastia, an adolescent with hypogonadotropic hypogondasism and a low IGF-1 (likely secondary to anorexia).

Bara light box: reviewing our patient's CT of the neck.
Ilona, Dr. Mandel, Prof Shires, Kershlin after rounds.

In the afternoon, I gave a talk on "An Introduction to Quality Improvement (QI) for Clinicians" based on my coursework for my Masters in Health Policy Research and my experiences doing quality improvement projects as a resident and fellow.

answering questions

Day Eight: Case of the day

Prof Shires has been following a 19 year old girl who had what had been called secondary amenorrhea because she had some spotting for 4 months, but on further history she reported never using more than 1-2 pads/day. Hormonal evaluation revealed elevated serum gonodotropin levels, normal prolactin, and low estradiol and IGF-1.  However, her breast development was consistent with Tanner IV/V and her pelvic US reported visualization of a normal size uterus, without a thickened endometrium and normal ovaries.  

We saw her during our endocrine clinic last week and hypothesized about the possibility of Turner mosaicism.  Her karyotype returned 4 days later confirming this.