The graph above, featured in Das et al’s paper “Rethinking assumptions about delivery of healthcare” (1), poses an intriguing and critical paradox. Doctors from around the world treat the hypothetical patient on paper very differently than the person who presents to their health posts. Das et al term the vast chasm between performance on clinical vignettes and standardized patient encounters as the “know-do gap.” One of the major implications of their finding is that global health’s commitment to improving access to clinicians – even knowledgable clinicians – falls short of ensuring access to proper care.
All of our clinical practices are probably affected by a “know-do gap,” whether that is from the effects of time limitations, bias, fatigue, or the bureaucratic brambles that get in the way of clinical care. In fact, I would be very interested in seeing what this “know-do gap” looks like in Boston hospital settings. While Das et al’s paper does not offer data for direct comparisons across urban/rural and low/high resource settings, I can hypothesize reasons that low resource, rural settings would face particularly stark gaps between physicians’ knowledge and their actions. I witnessed and began to experience some of the particular challenges posed by working within this kind of setting during my time with Compañeros En Salud in rural Chiapas. I spent ten days accompanying and mentoring a pasante* who is working as the primary care physician for a rural community.
The first reality I encountered is that the setting in which you practice changes the way you practice medicine by nature of what is available, knowledge aside. In general, I observed that in Chiapas the threshold to test becomes much higher and the threshold to treat lower, than in the US. For example, I met several women who presented to the clinic with dysuria. While urine dip sticks were abundant in the clinic, urine cultures and other tests like gonorrhea and chlamydia swabs were not available within a several hour radius. Compañeros En Salud had composed a clinical algorithm that included empiric treatment for vaginitis and cervicitis for dysuria that was unexplained by a urinary tract infection. Of course history and physical exam nuances informed medical decisions in the clinic. But it was interesting to observe the expectations for medical decision-making in this context. It is easy to see why the recommendations you write for clinical vignettes and those that you communicate to patients in clinic would vary significantly.
That said, the absence of testing and treatment modalities does not explain why patients in Bihar (in Das’s work above) were not recommended oral rehydration solution for their diarrheal diseases. Oral rehydration solution is composed of water, salt, and sugar – highly accessible therapeutic agents. What are some of the more intangible factors that explain the “know-do gaps” in low resource settings? One of the challenges I pondered during my time in the community was how to maintain curiosity about diagnosing less common disease processes in a setting where it is so difficult to confirm the diagnosis, either through testing or through second opinions by more senior physicians. Even after 10 short days, I had trouble avoiding premature closure (narrowing in too quickly on a diagnosis) in encounters with patients presenting with subacute diarrhea. We prescribed anti-parasitics broadly and had few other ways to test for other conditions. This approach was probably appropriate for the setting, but it was difficult to maintain a clinically curious mindset that would be necessary to tease out other diagnostic possibilities. Compañeros En Salud has made great strides to give the pasantes in Chiapas easy access to clinical supervisors and didactics. I imagine that these extra resources help bridge the “know-do gap.” But in other parts of Mexico, pasantes are essentially on their own, without much accountability, back-up, or mentors to push them in their clinical reasoning.
Das et al also highlight the incredibly short visit times (as low as 48 seconds on average in Bangladesh) observed in low resource settings. In Chiapas, I observed the opposite. The pasante I worked with spent up to an hour or more in her appointments, particularly with patients who presented with mental health problems. I joked with her that her job was not just doctor, but also surgeon/ psychologist/ priest for the community. Part of this pasante’s drive must have been personal. But I imagine her drive was also nourished by external resources such as a supervising psychiatrist who was “on call” via What’s App and access to a pharmacy stocked with anti-depressants and even anti-psychotics.
Global health work would benefit from learning more about what resources – material and abstract – factor into the “know-do gap.” One way to learn more is through participant observation in a clinical setting like the community clinics in Chiapas. Physician-policymakers could stand to learn a great deal from the kind of experience made available by Compañeros En Salud and the Global Health Bootcamp.
*Upon graduating, first-year clinicians in Mexico (known as pasantes) complete an obligatory year of social service.
1. Das, Jishnu, et al. “Rethinking assumptions about delivery of healthcare: implications for universal health coverage.” BMJ (2018): k1716.