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