Thursday, February 09, 2006

Thanks, Kyle and Joy, for a nice visit and this photo of a dik-dik!

Wednesday, February 08, 2006

Clinical Journal

It has been some time since my last clinical posting. I thought I would take this opportunity to bring you up to date on the clinical happenings at Muhimbili National Hospital.

The strike among the interns and residents has finally come to an end. Shortly after my escapade of dodging the demonstrating group of interns and residents (see blog post on 11/26/05), the physicians on strike quickly lost public support.

About five days after the strike was initiated, hospital administrators offered to double the salary, from approximately US $200 to US $400 a month, of the interns and residents. However, they turned down this offer and continued their demand for US $1,200 a month.

The hospital administrators were then able to use the press in painting a picture of young, greedy physicians who care more about making money than treating sick patients. This shifted public support from the interns and residents.

The following week, hospital administrators fired the striking interns and residents, and brought in outside physicians to fill the void. Physicians from the military base, public health agencies, and the Ministry of Health were called upon to stop their ongoing work and report for clinical duty at the National Hospital. Most of these physicians were not used to the complexity of Muhimbili patients, the country’s main referral hospital, and many of the physicians simply hadn’t seen patients in several years. In all, the medical care became sub-standard, even by Tanzanian standards. The hospital stopped admitting any referral patients and many people started going to other hospitals for medical care.

At one point, we were down to 6 patients on my ward. Our ward normally operates with about 20 patients and has the capacity for even more, usually by putting mattresses on the floor. The medical care was less than ideal and I was taking on more responsibilities, which I didn’t particularly want to do.

A couple of weeks later, hospital administrators agreed to rehire the residents, but not the interns. Residents were requested to submit an official apology letter by the next evening. The Internal Medicine residents submitted their letter by the deadline, but the Obs/Gyn and Surgery residents were too late. The Pediatric residents were traveling at the time, so they were spared of the deadline. Thus, the Internal Medicine and Pediatric residents, which is about 15 people, were rehired among the striking group of about 300 interns and residents.

In the meantime, the rest of the interns and residents were without a job, and the duties of the supervising physicians, which are seeing patients two times per week, remained the same. Patients would go for three, four, or often five days without seeing a supervising physician.

When no physicians would come for medical rounds, I would run the major ward rounds with the medical students. Even though I would cringe each time they wrote in a patient’s chart “MWR with Dr. Paul”, I knew there was no alternative. If it was a Friday, patients would be lying in bed until Tuesday, up to five days, without appropriate medical care. So, we would do what we had to in order to get them through to Tuesday. We also couldn’t wait to follow-up on some lab tests. If we suspected malaria, then we needed to treat for malaria. After some time, a schedule of clinical time was developed for the replacement physicians, and the situation gradually improved.

In the middle of December, presidential elections brought in an new president and administration. The new government quickly brought resolve to the issue. At the beginning of January, most of the remaining Internal Medicine interns and residents were rehired. The Interns were excited to have their jobs back. One later told me, “We went for over 2 months without work or pay. We were just sitting at home doing nothing”.

This week, about 3 months after the strike was initiated, the full events of the strike have come to an end. The pharmaceutical interns returned on Monday, and they were the last group to return to work. In the end, all of the interns and residents agreed to a salary increase of 100% (to US $400 per month), not too bad, and also to never strike again.

The administration did manage to divide the striking interns and residents through their rehiring process, as I feared they might. They required each person to resubmit a job application and held interviews to learn who was behind the strike.

There are 29 physician interns who were not reinstated in their medical training. These interns were considered to be the ‘ring leaders’ of the strike. As a result, they will have to wait one year before they are able to resume their medical training.

In the end, the interns and residents who came back to work broke their association from the strike and accepted their positions knowing that certain people were not being rehired. This defeat to the solidarity of the strike will make their future bargaining power less solid. However, they have decided to accept a salary increase and continue seeing the country’s poorest medical patients.