I had hoped to spend my elective in some busy general hospital, seeing terrifying things and learning a lot. It hasn’t really turned out that way, but my time at the river clinic is showing me something else instead.
This is ‘GP land’, as they say at home, but with little capacity to do anything beyond the basics. No friendly ambulance a phone call away; few diagnostic tests. GP land in extremis. Sitting at the doctor’s table in our one-roomed floating clinic, I watch the local villagers as they come in – often barefoot, mums breastfeeding, stooped old ladies, kids staring wide eyed at the strange white doctor. Some are really sick; others are here for their weekly health check, taking advantage of the free clinic and its medicines.
Often the doctor and I have three sets of notes at once as a young mum presents her runny-nosed toddler, her feverish baby and her own painful abdomen all at the same time. We see lots of common things – a boy with bacterial conjunctivitis, an elderly woman with a painful hip, a small child with a chest infection. Our tools are a stethoscope, auroscope, pen torch and The Oxford Handbook of Tropical Medicine. The contents of the drugs box have been selected carefully for the setting – metronidazole, ciprofloxacin, albendazole, paracetamol, oral rehydration salts.
I can see how useful the clinic is, in this location so far from any other formal health care, but from a medical perspective I find it quite frustrating. Perhaps I’m too inexperienced in primary care. I wonder how many people here have HIV and other STIs, and realise that probably nobody knows.
A young woman presents with vaginal discharge, and the doctor asks me what I think we should give her. “Well…what colour is the discharge? Is it itchy?” I can’t speak Khmer, so the doctor is translating the histories for my benefit. “She says it’s clear, and a bit itchy. What do you think?” I’m not feeling great about this. Even if I wasn’t just a medical student, I’m pretty sure I’d still be reluctant to make a diagnosis based on three words: ‘clear’, ‘itchy’ and ‘discharge’. “Can we have a look at it?” I ask. “She doesn’t want to show us”. I’m not really surprised. Anyway, the team dentist is seeing another patient behind the curtain. “Can we ask about sexual partners?” “Well she’s married”. “Is her husband likely to have other sexual partners?” “Sure. But we can’t ask her that.”
In the end the girl goes away with metronidazole and clotrimazole to cover all bases, and I’m left with a sense of futility. Without knowledge about STIs, and without her husband’s co-operation, she’ll be back again and again and again. I realise that, without good public health and education, doctors are simply footmen servicing a giant revolving door. In a way it’s why I like general practice so much – through patient education, primary care doctors get to prevent illness, or at least treat it before it gets bad. It’s frustrating to see a situation where there are so many obstacles to health.