TES Ambassador Exchange Soweto: Day three: Bara and Sebokeng

So today we split up in the morning and both had amazing experiences.

Dr. Mandel remained at Bara with the endocrine team. She first visited the pediatric clinic where pediatric endocrine fellow Kebashni Thandrayen and consultants Kiran Parbhoo and Fatima Moosa, who do both pediatric endocrinology and general pediatrics, had arranged for evaluation of several patients with metabolic bone disorders.

I went with Dr. Pauly and Lafundo to the diabetes clinic at Sebokeng, one of the remote townships about 45 minutes south of Johannesburg, to experience diabetes care in one of the primary health care settings.

Dr. Mandel's Day:

Dr. Fatima Moosa, Dr. Kiran Parbhoo, Dr. Mandel, and Dr. Kibashani Thandrayen.

The Bara pediatric metabolic bone clinic, staffed by Professor John Pettifor and Dr Kebashni Thandrayen, has become well known as a referral center.

Rickets is the most common reason for consultation here. Mostly nutritional, it affects children who have moved from the more rural and suburban type communities to urban city flats where play is generally restricted to indoors. The Bara pediatric metabolic bone clinic, staffed by these three physicians, has become well known as a referral center. In fact, two of the patients seen today were referred by other physicians and hospitals because of the academic and clinical expertise here at Bara.

First, a 7 year old girl was presented to me with hypophosphatemic Rickets. Please see the case of the day for details about this case.

The next several children had osteogenesis imperfecta and presented with fractures early in life. One family had multiple affected members including the mother, two children (girl age 3 and boy age 7) as well as aunts, uncles, and cousins. Prior testing done in the private sector revealed a mutation in COL1A.

Dr. Mandel playing hide-and-seek with one of the children with OI.

Pedigree of OI

The Mom expressed her gratitude for the care at Bara. She said that prior to her referral here, in the private sector, the phyisicans were not treating her children but just treating their fractures. Her children only started to receive q 6month zolendronic acid when they were referred to this clinic.

Lastly, I saw a young girl with McCune Albright, who began to have irregular menses at 4 months of age that became monthly by age 2. She was first seen at Bara at age 7, already with an adult bone age. Again, the Mom’s appreciation for the endocrine team’s care of her daughter was clearly evident.

I then left the pediatric sector and attended Endocrine Grand Ward Rounds, no not a formal talk presentation as we use this term in the US, but more like our endocrine inpatient consultation rounds. Prof Shires, endocrine consultants (Sindeep Bhana, Nazeer Mohammed), endocrine fellows (Kershlin, Vicky), residents, and interns rounded on some of the inpatients with endocrine disorders. We saw two patients with Graves’ disease, both significantly hyperthyroid where the Graves’ disease aggravated pre existing medical conditions. We also saw a woman with significant hypercortisolism, most likely due to ectopic ACTH secretion, but work-up still in progress. Bedside rounds are the norm and provide a setting for both didactic and clinical teaching. Prof Shires demonstrated key physical examination findings, asked questions, and solicited answers with exemplary educational skills.

The endocrine team rounding on the wards at Bara.

Ilona's day:

Bara to Sebokeng

On the ride to the clinic Dr. Pauly and I discussed the differences between the education system for endocrine fellows in the US and SA. We also shared some common frustrations in the care of diabetic patients. Ensuring our patients are able to have a consistant supply of diabetic supplies and medications can sometimes be challenging in both health systems - for slightly different reasons. For me , it can be challenging when a patient's insurance changes or he or she loses medical insurance (usually due to losing a job). Suddenly, the insurance no longer covers supplies for the patient's current meter - requiring patients to buy entirely different test strips. No wonder there is a black market for diabetic supplies in Philadelphia! Additionally, a patient's new insurance may now cover a different insulin regimen or no longer cover their oral hypoglycemic. Some patients will call the clinic to notify us, but others do not.

The medical formulary is much more limited here, for the patients at Bara and Sebokeng. All patients have an accucheck meter and the insulins are limited to N and R, although a limited number (30) patients at Bara have access to the rapid-acting analogues. Patients here all have insulin pens, which has really improved compliance. Oral medications are limited to metformin and the sulfonylureas. When the formulary is limited (we have the same restrictions at the health district clinics in Philadelphia), it is easy to know what medications are covered; however, the difficulty is that some times the local pharmacy may not have the medication a physician orders for the patient and the patient may not return back to the pharmacy when the medication is in stock. Additionally, the lines for the pharmacy can be hours at Bara. Many times when this happens, a patient may not receive the medication until they have seen a physician again. Additionally, patients here are limited to 50 test strips a month, making the care of diabetic patients on insulin quite challenging.

The clinic at Sebokeng

We saw about 20 patients in clinic, primarily patients with type I diabetes. Dr. Pauly also helped staff patients seen by a registrar. Over the past several years, the physicians at Sebokeng have made great progress in decreasing the mortality rate of patients with type I diabetes. Prior to the implementation of DKA protocols and the institution of consultant physician clinics, the mortality rate for patients with type I diabetes admitted to the Sebokeng hospital with DKA approached 50%. For several of the patients we saw in clinic today, the primary goal was preventing hospitalizations and mitigation of the symptoms of hyperglycemia. One of our patients was a 21 year man who was still in school, in the 11th grade. He explained that he had been hospitalized so frequently since his diabetes diagnosis in his teens that he was unable to attend school. Once the goal of preventing hospitalization for DKA has been achieved, the focus can then shift to a goal of preventing longterm diabetic complications.