The Last Hurrah

For our second to last day of training, we spent all day in the clinic and I have to be honest I was kind of dreading it. It is literally the most exhausting thing to try to manage trainees. I am at St. Paul’s essentially by myself with two clinics seeing patients at the same time. I have nurses who know how to do VIA/Cryotherapy in each of the clinics but neither of them know our study protocols so I have to be watching everyone like a hawk to make sure that the consent forms and surveys are done, plus making sure that they fill out the forms correctly. I also need to watch them do the screening to ensure they do all the steps adequately.
            Although I had less trainees with me today, Alisa wasn’t able to help me out in the other clinic so I had to run back and forth between the two ensuring that all the paperwork was done and that everyone had enough copies of all of the forms.  Luckily the other room was completely on top of it, but it was still really stressful. Then I had women again pounding and pushing on the door and on me to be screened as I pushed them back. It’s great that everyone is so enthusiastic, but it makes me immensely stressed out to physical force patients away. One woman was particularly persistent that her 63 year old mother be seen and would not listen to me when I tried to explain that we are only seeing women up to age 45; however, she barker her way into the room telling me that she was a doctor with the ministry of health and proceeded to question me on the details of the study. Of course, this caused me to be a little flustered and a little irritated that a so called professional would be so aggressive with me right off the bat. I quickly stepped out and called Dr. Goedken asking her to ensure that a head physician of the project be here at all times in order to help me keep the peace since no one really listens to the white girl. We aren’t really sure if this woman was actually with the ministry of health, but we screened her mother anyway. I felt a little guilty that I had treated her a little brusquely since all she wanted was help for her mother, but her first reaction to me was so hostile that I couldn’t help but respond with a little force behind my words. Maybe not the best way to have handled it, but I was trying to juggle fifty other things that my stress got the best of me.

Ethiopian physicians have literally no concept of IRB or patient awareness. It was a point actually brought up at the MEPI workshop I attended Thursday morning, but in a slightly different context. The leaders of the conference said that in recent years, the IRB process here has become more stringent (my roommates and I can attest to that!) out of a very real fear that developed countries doing research in low resource areas often take advantage of African patients. However, they have become so strict in their policies that it is almost impossible to get any project approved and the committee nit picks over minor details in order to exact some sort of control. Even though they continue to stone wall research and tout the idea that “policies” must be followed, the physicians here have no idea what they are even upholding. There is no such thing as privacy here and a woman’s medical information is discussed openly in front of others. They do not understand that patients need to be the final decision makers in their medical care and sweep patients into treatment fast tracks without stopping and really discussing options with them. For example, the woman from the ministry of health was furious that I was denying her mother care and questioned my IRB approval, but when I explained to her that I didn’t have approval to screen her mother because she didn’t fall into the appropriate age range, she didn’t seem to care so much about the IRB approval then. The patients here are denied so much due to lack of resources that when they become available, it’s a mad dash to the clinic door regardless of protocols or patient rights.

Somehow I survived the day and spent the evening with Dr. Goedken, Alisa, and Sunyiat, an OB/GYN from Michigan and Ethiopian ex-pat, at Dr. Dawit’s house as he had invited us over to dinner to meet his wife, Tigi, and their newborn son. Barkau (no idea how to spell it, but it means “blessings” in Amharic) was the sweetest little baby and made the most hysterical faces. Definitely gave me some baby fever. We had a wonderful dinner of Ethiopian food, fish, and vegetables, and we eagerly stuffed our faces because by the time we actually ate it was almost 9:30pm. Dr. Dawit kept the wine flowing and was a little over generous with my glasses if I do say so myself. We were all getting a little louder and a little looser as the night went on and the rainstorm outside pounded down on top of us. By 12am we decided it was time to head back to the hotel as we still needed to write the exams for the participant testing in the morning. Finally by 1:45am, I was on my way home, but not without some aggressive habesha bargaining with the cab driver on my part. Unfortunately the power was out in our house and my phone was dying so I was slightly panicked that I wouldn’t wake up in 4 hours. I lay in bed and mentally repeated my wake up time in my head hoping that I wouldn’t sleep in, but luckily my phone lasted the night and I was off to the Desalegn Hotel yet again at 6:45am.

When Dr. Goedken and I met up over breakfast, we realized we had some last minute details we needed to tie up so I headed over to St. Paul’s to have our training certificates signed by Dr. Abdulfetah and buzzed back as quickly as I could given the Lada taxis here don’t go much about 15mph, and made it back in time for the testing. Everyone did very well on all of the assessments and passed with flying colors! We handed out the official training certificates and sadly said our goodbyes. I am proud to say that we have officially trained 15 new healthcare professionals how to screen for cervical cancer using VIA! I can’t believe it’s all actually over. I have spent the past two months dedicating my life to this project and it’s unreal that the largest part is done! I still have the “data” to review, the papers to write, and possibly the return trip in December if we get funding, but my training “baby” as I refer to it, is all said and done. Thank goodness. 

The whole group! From the left: Fikirte, Hussen, Mesfin, Terafeyuw, Zeleke, Jalel, Tilahun, Sherangizaw, Dr. Goedken, Abebe, Fikre, Dr. Hezkiel, Me, Nigussu, Dr. Dawit, Genet, and Betre

Dr. Hezkiel, me, and Dr. Goedken. Yes, Dr. Hezkiel is holding my hand. All Ethiopian friends, whether its two men or two women or a man and a woman, are very affectionate and always hold hands. So habesha.

Dr. Dawit, ladies man.

The whole group!

The certificate of training. So official looking!

Designated Wrangler

We are officially beyond the halfway point! It’s hard to believe that the training is almost over and we are well on our way to celebrating a successful week! This morning Dr. Goedken was nice enough to invite me to a Medical Education Writing Workshop at the Sheraton Hotel sponsored by MEPI (Medical Education Partnership Initiative) before heading into training this morning. It actually was very useful and really broke down how to take an aim or question and translate it into a publishable work. Both Dr. Goedken and I agreed that the course would be a great addition to Socrates, our medical research weeklong course at Emory, which definitely left something to be desired. While I was thinking about future medical research and how useful this information was, the course also made me think about my own personal writing and how to move forward with it in the future. My goal has always been to write a novel and I’m hoping that my time here gives me the experience and the opportunity to pursue that! I keep telling my roommates that if surgery doesn’t work out, maybe I’ll just go with my original idea to be a writer. Sounds a lot easier these days especially as I work on my residency applications and begin to face the reality of moving on from the safety of school and into life as an intern.

            After the workshop, we were picked up by Dr. Dawit and headed to Black Lion. On the agenda this morning was a debriefing session from yesterday’s clinical experience and then more practice with cryotherapy and VIA images. Also worked in there was my lecture about infection prevention practices in the healthcare setting and in the VIA clinic. It was a pretty bland lecture, but I think it went well! I also showed a video from MAF or Medical Aid Films which showed the necessary steps for decontamination and disinfection in the VIA clinic. It was actually a really clear and useful video, even though it took a bit to load given the tricky internet situation in the hospital.

Me giving my lecture. Everyone is obviously riveted. I tried to make a joke and heard crickets. 

            Right before lunch, the chief resident Samson kindly let us know that none of the residents would be able to attend tomorrow or Friday due to having to administer medical student exams. It seems like the medical students have exams every other week and the whole hospital literally shuts down when they do. No one rounds because the medical student is the one who collects the patient history and no operations are done because all of the residents and attendings are administering exams. I understand that everyone needs to be a little more patient in teaching hospitals but the idea that the hospital slows to a halt during exams is a little odd to me. Anyway, luckily we rearranged the schedule so the residents can complete the training and attend the testing, but that little hiccup almost gave me an ulcer.

            The afternoon was again spent in the clinics having the residents practicing VIA on participating patients. We finished around noon so I took my time with lunch as I figured most of the residents would. At around 12:45 I looked around for my group and they were all gone! I was supposed to pay for the residents to take a taxi cab to St.Paul’s, but apparently they left without me. So Alisa and I made our way over. On the way, my cab driver quizzed me in my Amharic knowledge and I am now proud to say that my vocabulary has greatly expanded. I can now count to 30, ask a man or a woman their name, how they are, etc, and know various other words. Anytime we stopped talking, he would take it upon himself to ensure my understanding and randomly test me on a number or phrase. It was hysterical. I can’t say I did very well, but I tried!

            When we arrived at St. Paul’s, the residents were nowhere in sight and I began to get a little panicked. I also was unable to get in touch with Dr. Abdulfetah who was supposed to be overseeing the clinic. Finally, the residents strolled in already to go and started setting up the clinic. The patient charts started stacking up and it looked like it was going to be a very productive day! Unfortunately we were beginning to run low on consent forms, the VIA exam forms, and the surveys so I ran across the street to make copies, which worked surprisingly well, and hurried back. Initially the residents were doing so well—counseling the women, ensuring they had filled out the forms, and doing thorough exams, but about an hour into the day everything just fell apart. The charts piled way high and women were literally trying to push their way into the exam room while I pushed back to barricade the door. In their attempts to move things along quickly, the residents shuffled all of the charts and all of the paperwork I had organized by patient number. They forgot to go over the consent forms before the patient got undressed and up on the exam table and didn’t have the patient leave the room to fill out the surveys. The surveys are supposed to have the patient rating the services they received so if filled out in front of the residents, there is a huge potential for bias. Plus, the patients don’t even understand the first question because the Amharic translation is off and makes it a double negative, which not surprisingly patients find very confusing. My data may be totally bogus, but oh well!

            Finally the day wrapped up and we got ready to head home. We had to send away 4 patients and tell them to come tomorrow because we were so swamped. When all was said and done, I headed over to Desalegn hotel to meet with Dr. Goedken and make some changes to the forms we are using and our schedule. Both of us were slumped in our chairs, barely forming sentences out of pure exhaustion. She had to head to a MEPI dinner at Yod Abyssinia right after while I thankfully got to go home. At home, we started to clean the house and get organized as Karen, Chris, and I are all leaving this weekend. As much as I miss home, my family and friends, I am unbelievably sad to be leaving. This place, as loud and chaotic and often frustrating as it is, has become to feel like a second home and I will be really heartbroken to leave it. But there is hope that I will be coming back in December to see how the clinics are running and to collect more data, so maybe my Ethiopia and I will be reunited again. 

From Pork to Patients

            Another day done! The morning started with me rolling out of bed, still exhausted, and heading to the Desalegn Hotel. Luckily, there were no en route panicked phone calls and I relaxed for a little with my macchiato before Dr. Goedken came down in her usual blaze of bubbly energy. We chatted over eggs and toast and came up with a reasonable to do list and amendments to our schedule given our participants inability to be on time. Then we headed down to the lobby to meet Dr. Dawit who has been giving us rides to Black Lion. Dr. Dawit’s family actually owns the hotel, and he works there as a supplement to his income as a physician. Around 45minutes later, he pulled up in his car, sporting his Prada sunglasses, and off we went!

            Per usual, Dr. Goedken and Dr. Dawit worked on higher up details and talking with faculty while I ran around like a mad woman setting up the room, printing schedules and sign in sheets, and setting up the lectures. Luckily, we only ran 30minutes late this morning so I didn’t have to hassle people too much on time. We reviewed the steps of VIA and cryotherapy and then spent the rest of the morning practicing the two. We brought over two ZOE pelvic models and bought hot dogs, as I mentioned yesterday, to be used as pretend cervices to cryo. It actually worked remarkably well and the residents thought it was hilarious that we had little hot dogs on sticks stuck in the pelvic models. We had each resident walk through the whole process and spend extra time counseling the “patient.” Physicians here don’t really take the time to counsel or to make any sort of connection with the patient. Generally the patients are ignored and told what to do, so we spent a lot of time talking about choice, privacy and confidentiality. If you think things doctors have bad bedside manner in the U.S., you would be shocked here. I have seen doctors completely ignore crying women who have just been told they have cancer as they sign paperwork, so a little extra emphasis on how to talk to patients was definitely needed!

Hot dog's on a stick make excellent cervices apparently. Unfortunately, Dr. Dawit left them in his car over night so they smelled a little ripe. 

Dr. Goedken helping Mesfin adjust the speculum to show the hot dog cervix. 

            As the residents counseled, screened, and treated the hot dog cervices and rubber pelvic models, I was busy making copies of all the forms we would need for that afternoon. There were consent forms, patient follow up cards, education sheets, surveys, and VIA/Cryotherapy forms that all needed to be printed, copied and stapled. I’m telling you, I am mastering the art of being an assistant. Oh and the Ethiopian photocopy machine, which is finicky beyond belief. All of these forms have to be in Amharic, which can sometimes prove difficult with formatting. I’m not sure how to read it so can’t tell if the lines are in the appropriate place or what and was definitely admonished today by the attendings for my sloppy forms. Oh well!

Mesfin practicing VIA on Samson, OB/GYN Chief resident pretending to be the patient/obligatory hot dog in pelvic model holder. 

Practicing cryotherapy

Dr. Abdulfetah watching as Jalel practices cryotherapy.

            When the mini training and demonstration was over, the group heading to St. Paul’s, made up of 4 residents, one nurse, and one attending, quickly grabbed sandwiches and hopped in a cab. Well, really they all grabbed sandwiches, sat down and took their time eating, while I was standing, taking my lunch to go, tapping my foot and glaring at my watch. Oh habesha time…We eventually got there about 1pm and Nigussu, one of the nurses, and I, busied ourselves with setting up the clinic. It is even more noticeable to me how hierarchical the medical system is here. I am asked by everyone to do the most minor things simply because I am lowest on the totem pole. When asked something absurd, I tend to stand my ground, which the attendings don’t appreciate, but what can I say, my stubbornness usually wins out. Luckily, the clinic came together pretty quickly and we began to see patients within 30minutes or so. Half of the residents spent time in HIV VIA clinic that St. Paul’s already runs and the other half were with me in the non-HIV clinic. The hospitals here don’t really understand HIV transmission nor do they have good decontamination techniques so the HIV population is still heavily segregated in terms of procedural rooms where blood or bodily fluids could be involved.

Our little table filled with forms and patient charts. The OB/GYN residents would sit here and talk with the patients before performing the screening test. 

The other side of the clinic showing the patient table and our decontamination buckets. 

            Over the course of two hours we saw a total of 14 patients in the two clinics and all of the women tested negative for any precancerous lesions. As Dr. Abdulfetah, the OB/GYN residents and other trainees talked to the women and performed the screening, I was nagging everyone to obtain consent forms (preferably PRIOR to the woman undressing and putting her legs up in stirrups. This proved to be a difficult concept) and in my broken Amharic trying to have the women sign surveys. Of course, half of them didn’t understand the form, so I’m pretty sure my data will be horrendously skewed, but it all got done! We are surveying the women to assess the overall acceptability of VIA and cryotherapy. We basically want to see if women will tell others about it and view it as a positive experience, which is one of the ways we can hope to assure sustainability of the program.

            While we were busy at St. Paul’s, Dr. Goedken, Dr. Dawit, Dr. Hezkiel, and 5 OB/GYN residents were over at our other clinic in Black Lion Hospital seeing patients as well. Unfortunately, they only saw 4 patients over the course of the afternoon but were able to utilize cryotherapy to treat a precancerous lesion found. The rate of dysplasia in women is usually around 10-15% so unfortunately for the training, the residents won’t gain the experience in utilizing cryotherapy (the treatment modality) as often as they will the steps of VIA (the screening modality), which is done on everyone.

            Tonight I am busy preparing my lecture for tomorrow on infection prevention practices, which I am a little nervous about. Hopefully I don’t bore them to death and hopefully they take me seriously. I guess we will find out more tomorrow!

600 Condoms and A Pack of Hot Dogs

Well it’s official! Day one of the training has come and gone and I am happy to say that despite a late start, everything went off perfectly. Dr. Goedken arrived early yesterday morning so we met all afternoon to arrange last minute details with Dr. Dawit and Dr. Hezkiel. Dr. Dawit, the principal investigator on this project, has been traveling all over for the past few months and MIA in terms of the project (why I have been working exclusively with Dr. Hezkiel). Dr. Dawit was initially in London on vacation, followed by Canada conducting a training session, and then in Colorado as his expectant wife was awaiting delivery of their first child, so we had a lot to catch up on. Of course, despite the fact that I had sent out schedules and lectures almost three weeks ago, begging for approval and feedback, this was the meeting in which they wanted me to rearrange everything. So I busied myself with a to do list, being the good administrative assistant that I am, and tried to calculate in my head just how little sleep I would get in order to finish all of this work. After a quick coffee, we headed to Black Lion to set up the simulation lab with all of our materials. The lab where we are holding the training is a surgical skills lab donated by Johnson & Johnson and is absolutely gorgeous. It bears no resemblance to the dilapidated facilities it’s contained within and is constructed entirely of marble. Even the tables are marble topped! It contains projectors and screens, flat screen TVs, and laparoscopic equipment. It’s hard to believe this exists in Ethiopia, but thankfully for us, it does. At a small fee of course. 

The simulation lab where we are holding the training

Our training materials.

Our visual aides for learning VIA. Every participant got one of these to put in their respective clinics.

            Once we had set up our pelvic models, notebooks and charts, we headed to the grocery store to buy some extra supplies to outfit our clinics. Since we are trying to treat this VIA screening as a portion of an overall reproductive health checkup, we wanted to supply the women with condoms and sanitary napkins. Luckily, our budget is pretty extensive so we felt comfortable outfitting the hospitals with a substantial number to utilize after we leave. Not so comfortably, at least on my part anyway, we bought 600 condoms and almost 500 sanitary napkins. So here I am, being my awkward white girl self in Ethiopia, strolling the supermarket with a shopping cart filled with multiple economy sized boxes of Sensation condoms, ribbed for extra pleasure of course. I got a few stares as did Dr. Dawit and Dr. Goedken who were with me. As Dr. Goedken said, they probably wanted to know how this Ethiopian man scored two Farenji women. That of course, made it even more awkward.

            I spent the evening at Lime Tree, with Dr. Goedken and Alisa, the PGY-4 OB/GYN resident, catching up, and I, stuffing my face with pizza and chocolate cake to soothe my nerves and frustrated anxieties. All the while, I am praying that Friendship supermarket doesn’t close so I can run to and buy multiple packages of hot dogs that we will use tomorrow to train the residents in cryotherapy. Apparently the end of a hot dog looks like a cervix and mimics the consistency of human tissue, who knew? Luckily, my amazing roommates were able to grab some for me and I could breathe easy knowing one of my tasks was done.

            I finally got home at around 9:30pm and quickly got to work creating two new lectures, amended two old ones, re-writing the schedules, going over my presentations, and resending all of this material to those involved in the training. Of course during all of this, my internet wireless stick ran out of money and stopped working and I almost fell asleep multiple times, but finally around 1:30am, I finished my list. I wish I could say I crashed into bed, but my nervous energy kept me bouncing around until my alarm blared at 5:30am. Off to the Desalegn Hotel I went to meet Dr. Goedken for breakfast and to discuss other concerns we had. On the way, I received a phone call from Dr. Goedken telling me about even more changes that I needed to make, so I busied myself on my computer in the cab ride over. My driver told me I work too hard and wanted to know when I was going to focus on having babies instead. Oh dear. 

            I’ve had a lot of time to reflect on Discovery over the past couple of months and have realized that my project really has nothing to do with medical research despite what our curriculum says. In reality, I have spent this summer experimenting as a glorified administrative assistant. I have made schedules upon schedules, set up meetings and canceled meetings, facilitated purchases and deliveries, printed literally thousands of sheets of paper just so that when my attendings meet, I can literally redo it all again to their liking. I have dealt with people being unreachable, with people talking down to me because I am a medical student, and simply put a smile on my face to get the job done, but even now that it is almost over, I can’t say that I’m relieved. It could be the lack of sleep talking, but I am pretty frustrated that I almost feel as if my role in this project has been viewed as inconsequential. Regardless, the project is not about me and is really about the women here, but still, it’s hard not to feel a little let down after all this struggle and so little recognition.

            Dr. Goedken and I quickly ate our breakfast and met with Dr. Dawit in the lobby. Of course, even though it was 7:30am and we needed to be at the hospital at 8:00am, he insisted we could have coffee and still be on time. Sure. At 8:20am we arrive at the hospital and I run up the stairs as our training is scheduled to begin in 10minutes during which I need to set up the projector, print the schedules, set up the room, and overall prepare everyone for the day ahead. Of course this entire time, I am being admonished for my lack of flexibility and inability to conform to “habesha time,” but I find the whole idea so ridiculous, I can’t budge unless in a completely disgenuine way with a strained smile on my face. I understand the need to assimilate to another’s culture when trying to enact change, but the idea that you have to budget an extra hour into a training, a training that you have spent literally thousands of dollars on to give free medical training to residents, because they will all be late (for no good reason either, mind you) is absurd to me. Also, when planning yesterday, we were told we needed to buy notebooks, pens, and bottles of water for every participant as this was expected from presenters. I think they forgot to note that this is what is expected from white presenters. Anyway, I digress.

            At 9:30am, the residents begin rolling in and much to my amazement, all nine senior OB/GYN residents, 3 nurses, and two attendings were present, meaning we that we are training a total of fifteen people. We began our day with introductions and lectures, discussing the pathophysiology of cervical cancer, counseling women, and even doing role-play (with me as the Ethiopian woman of course) so that the residents could practice answering common questions. We even had two tea breaks with coffee and cookies and a wonderful lunch catered to us! I couldn’t believe that so many different components came together so nicely. Despite our late start, we finished a whole hour early, much to the joy of the residents.

Dr. Goedken giving the first lecture

Dr. Hezkiel lecturing about HPV and cervical cancer

Dr. Dawit lecturing about the pathophysiology of cervical cancer

The afternoon was spent freezing hot dogs as practice and more grocery shopping. Tomorrow we are starting the clinical practice portion of the training, which is the last big hurdle of this week. Hopefully all will go smoothly and we will have patients actually show up to clinic! Keep your fingers crossed. 

            As my eyes are sagging and my stomach is in knots, I am having trouble balancing my thoughts of pride in the success of the first day and the frustration I feel as I am used as a menial laborer. I know it’s the role of the medical student, but it’s hard to swallow at the end of today. Despite my best efforts, this project has become really ingrained in me and to feel as if I no longer have control is difficult. I guess it’s a good lesson to learn as I continue on in my training, but today I am feeling a little worn out.