I thought that after applying to medical school, residency, and fellowship that these incredibly common, yet deceptively difficult (“why medicine? why OBGYN?”) questions would cease. I’ve always struggled answering them. The answers sound either trite, disingenuous, or pompous. No one wants to carry a conversation with someone who just proclaimed that they were wanting to save the world. But as I’ve transitioned from an OBGYN resident at BMC to part time faculty at BMC and global health fellow at MGH, I’ve been getting this question a lot. I’ve also been asking myself this question a lot.
As I’m nearing the end of my first of four trips as an OBGYN consultant at Sagam Community Hospital in western Kenya (through the MGH Global Health Innovations and Leadership Fellowship), I’ve been ruminating on how to best answer that. And honestly, it is because it is a lot of fun. Not fun in the way you think – traveling, greasy street food, and less paperwork (though those are definitely perks) – but in the nerdy, academic way. Medicine is fun again. You get to problem solve like the Apollo 13 engineers, fitting square pegs into round holes. For the past 2 months, I’ve been working without studies applicable to this patient population. I’ve only had guidelines from the WHO and Kenyan Ministry of Health which, while comprehensive in their own rite, have proven too broad and usually not applicable. The antibiotics I have one day are not the ones I have the following day. The only feasible imaging is what I can personally do with a portable ultrasound.
When you are in medical school, learning physiology and pathophysiology for the first time, you get to actually think about how that specific drug works, and why it may or may not work for the situation at hand. You get to problem solve for the test, though never on patients, where it matters. But as you progress in residency and memorize all of the hospital protocols, society guidelines, and sentinel articles, you rely more and more on those and less and less on what you learned back in medical school. Maybe this is more true in obstetrics, I’ll let my non-OBGYN readers comment on that, but at least this is how I feel practicing at a resource-rich, urban, academic center. Sometimes working on labor and delivery in Boston feels like you only have to be good at recalling protocols, finding information, reading literature, and following flow charts. There even is a certain amount of prestige that accompanies being able to cite the most recent ACOG Practice Bulletin or that practice-changing NEJM article during rounds. I am not trying to disparage this type of medical care as there are benefits: it’s largely evidence based, standardization of care reduces variation and errors, and it protects us from litigation. So how does this style of medicine translate to resource-poor, global, settings? Initially, not well.
An example. A woman presented on a Monday morning, stable, with a fetal demise at around 25 weeks. She was induced at an outside facility without success. On admission, our bedside ultrasound showed what looked like an extra-uterine pregnancy adjacent to a non-gravid and laterally displaced uterus. Or was it a cornual ectopic? Or was it a bicornuate pregnancy? Or a pregnancy in a rudimentary horn? Where was the placenta and what was it attached to? So many questions! I know what I would’ve done in Boston though. I would have sent for a confirmatory transvaginal ultrasound with a trained sonographer to be read by a radiology attending, then I would have gotten an MRI, then I would have discussed with my senior maternal fetal medicine and gynecologic oncology colleagues for surgical planning. I lastly would’ve asked urology to stent her ureters intraop.
That is all well and good, but I only had a fellow OBGYN consultant, an operative family medicine attending, and a senior clinical officer who could only give ketamine sedation. No anesthetist. No ICU. So we all sat and talked it through. We thought about what it could be, what could be the worst case scenario, what could the best case scenario, and everything that could possibly go awry. It was probably the most invigorating medical discussion that I’ve had in a long while. The same level of excitement that I felt as I shadowed in the wards as a first year medical student. In the end, we took her to the OR (theatre) on Tuesday for an ultrasound guided cervical dilation under ketamine sedation which suggested there was no connection between her cervix and the pregnancy. This was not coming out vaginally. The next step was an exploratory laparotomy the next day. I had never been that anxious for a surgery as I was that Tuesday night. I saw the grainy ultrasound replay in my head again and again and second guessed each decision we had made. I considered where the ureter may be, how the vasculature may be abnormal, how to deal with the placenta, and seemingly hundreds of other “what-ifs”. But come Wednesday morning when we called “skin incision!”, though I was yearning for those radiology reports and those expert opinions which I could not have, I found that I was actually the most prepared for any case I’d been a part of. I knew that I was a good surgeon, that I had another good surgeon across the table, and that we had done everything available to us to prepare for the worst while hoping for the best. Ultimately, we discovered that she had a cornual ectopic, which we resected. There were no apparent complications, she retained her uterus, and she went home three days later.
I tell you this not to make myself feel good; though there is certainly power in processing and reflecting. I tell you this not to make you feel bad for the providers or the patients; because this hospital has an impressive set of resources (human and otherwise) – more than I had anticipated. I tell you this to illustrate my point.
I’m not advocating being a cowboy (or hot-dog as was used in my residency) and making things up as you go. I wish I had protocols to tell me exactly what to do with that exact patient given those exact resources. I wish I had scholarly articles telling me the incidence of cornual ectopics, extra-uterine pregnancies, and Müllerian abnormalities in rural western Kenya. I wish that I had an MRI scanner and ureteral stents. That is what all my Boston training had instructed me to ask for. But you don’t; and I didn’t that day, always have those luxuries.
So what am I trying to say here? I think a few things. Yes, it is challenging to learn what feels like two forms of medicine as you share time in America and resource-limited settings. Yes, the way I was trained and how I practice medicine in Boston does not always serve me well in Kenya. No, I didn’t receive poor training, in fact I received fantastic training; that is why I am doing a global health fellowship, to learn how to bridge this gap. I am learning again how to use my physiology, pharmacology, anatomy and strong medical foundation to problem solve when I am exposed to limited resources. But it doesn’t have to stay here in Kenya. These same skills: critical thinking, being flexible, creativity, and problem solving can only make me a better doctor back in Boston. This is why I am spending two years on a global health fellowship. And this is why I am doing global health.
And in case you were wondering: I wanted to be a biomedical engineer in college because I wanted to bridge basic science with human experience, I wanted to go into medicine because of my personal experiences with my doctors, I wanted to be an OBGYN because I wanted diversity in practice and the ability to work internationally, and if you even think about asking me why I wanted to go into global health, I’ll ask you to kindly re-read this essay.